Notification

STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point-of-Service (POS) Products


Notification Issue Date: 10/01/2014

The new Medicare Advantage policy portfolio that includes this policy bulletin will become effective on 01/01/2015.



Medicare Advantage Policy

Title:STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point-of-Service (POS) Products
Policy #:MA00.021a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

For Health Maintenance Organization (HMO) and Point-of-Service (POS) products, STAT laboratory (lab) tests performed in an outpatient hospital setting are covered and eligible for reimbursement consideration by the Company when they are performed to obtain immediate results to assist in determining an individual's course of treatment. For a list of eligible STAT lab tests, refer to Attachment A.


Precertification and referrals are not required for the STAT lab tests listed in Attachment A. These tests may be performed by any participating hospital laboratory, provided that a participating provider (ie, the individual's primary care physician [PCP] or specialist) requests the STAT lab test via a written order.

Lab tests that are not included in Attachment A require precertification if they are to be performed on a STAT basis. When ordered in conjunction with STAT lab tests, routine lab tests require precertification in order to be eligible for additional reimbursement consideration.


Policy Guidelines

Participating primary care physicians (PCP) and specialists may direct any STAT laboratory (lab) test to any participating hospital with a written physician order.


Routine lab tests and those not listed in Attachment A must be directed to the PCP-designated laboratory site for Health Maintenance Organization (HMO) and Point-of-Service (POS) products.

In geographic areas with a capitated lab program, STAT lab tests listed in Attachment A and performed in an outpatient hospital setting that is the member's designated cap site are included in the capitation payment and are, therefore, not eligible for separate reimbursement.


Description

Laboratory (lab) testing is an important component of clinical treatment and is performed to provide information for the diagnosis, prevention, or treatment of disease, or the assessment of an individual’s health.


At times, it may be necessary for providers to perform specific laboratory tests to obtain immediate results to assist in determining the individual's course of treatment. These tests are defined as STAT lab tests and are performed in the outpatient hospital setting.


References

Partners in Health. Provider Manual. November 2006.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to Attachment A for a listing of STAT laboratory tests.


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point-of-Service (POS) Products






Policy History

02/09/2015This policy has been identified for the CPT annual code update, effective 01/02/2015.

The following CPT codes have been revised on this policy:

86900: Blood typing, serologic; ABO

86901: Blood typing, serologic; Rh (D)
01/01/2015This is a new policy.




Version Effective Date: 01/02/2015
Version Issued Date: 02/09/2015
Version Reissued Date: N/A