CMS Eliminates Requirement For IL’s To Bill Each AMCC Test

Effective for services on or after January 1, 2012, CMS eliminates the requirement for Independent Laboratory (ILs) to bill separately for each individual Automated Multi-Channel Chemistry (AMCC) laboratory test included in organ disease panel codes for ESRD eligible beneficiaries. Organ disease panels will be paid under the Clinical Laboratory Fee Schedule and will not be subject to the 50/50 rule payment calculation when billed by ILs.

ILs were required to bill for each individual laboratory test included in the organ disease panel and use the following modifiers with each code to identify which tests were included in the composite rate and which were separately payable:

CD – AMCC test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is not separately billable

CE – AMCC test has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity

CF – AMCC test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable

Claim editing was put in place that would allow ILs to bill (and be separately paid) for bundled laboratory tests performed on ESRD eligible patients so long as the service is not related to the treatment of ESRD.

If a Medicare beneficiary is not receiving dialysis treatment (for whatever reason), the ILs may bill Medicare directly for any laboratory test it performs. However, while ILs can now be separately paid for individual laboratory tests performed on ESRD eligible patients who are not receiving dialysis, the editing that disallowed billing of organ disease panel codes for ESRD eligible beneficiaries remains active.

Effective for services on or after January 1, 2012

The ILs will be paid under the Clinical Laboratory Fee Schedule and will not be subject to the 50/50 rule payment calculation.

CMS will allow organ disease panel codes (i.e., HCPCS codes 80047, 80048, 80051, 80053, 80061, 80069, and 80076) to be billed by ILs for ESRD eligible beneficiaries when the beneficiary is not receiving dialysis treatment for any reason (e.g., post-transplant beneficiaries); and Make payment for organ disease panels according to the Clinical Laboratory Fee Schedule and apply the normal ESRD PPS editing rules for ILs claims