The Clinical laboratories should pay close attention to two new Medicare transmittals that explain how to bill for the new hepatitis C virus (HCV) screening benefit since claims that violate frequency or diagnosis code requirements will result in payment denials.
The Centers for Medicare and Medicaid Services (CMS) transmittals, released Sept. 5, explain how to bill for the HCV screening benefit and incorporate the new national coverage determination in the Internet Only Manual Publication 100-03,
Medicare National Coverage Determinations. Transmittal R3036CP explains the billing requirements and updates the
Medicare Claims Processing Manual (Publication 100-04). Transmittal R174NCD updates the
Medicare National Coverage Determination Manual (Publication 100-03).
Both transmittals have effective dates of June 2 and implementation dates of Jan. 5, 2015, for nonshared Medicare administrative contractor edits and common working file analysis, and April 6, 2015, for the remaining shared system edits. This means that labs may not be able to depend on Medicare denials to detect claims that violate frequency or diagnosis code requirements on the effective date and must take action to avoid submitting inappropriate claims.
Transmittal R3036CP introduces a new Healthcare Common Procedure Coding System (HCPCS) code G0472, “Hepatitis C antibody screening for individual at high risk and other covered indication(s)” along with the necessary International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, Tenth Revision (ICD-10) codes that must accompany the new HCPCS code to avoid denials. It also provides the specific reason and remark codes that will be used with denials. The new information appears in the claims processing manual in sections 210 through 210.4.
CMS Exclusions May Cause Confusion
Under Medicare, HCV screening is covered for beneficiaries at high risk for an HCV infection. High risk means persons with a current or past history of illicit injection drug use and persons who have a history of receiving a blood transfusion prior to 1992. Screening tests for adults who do not meet the definition of high risk but were born between 1945 through 1965 are allowed once in a lifetime.
Annual screening is allowed for high-risk patients who have continued illicit injection drug use since the last negative screening test. Determination of high risk for HCV is made by the primary care physician and must be properly documented in the patient medical record. Once again, labs are at the mercy of physicians to order the HCV screening test only when appropriate and to properly document that service.
Hospitals and other institutional providers must use type of bill (TOB) codes 13X and 85X when billing with G0472. Note that TOB 14X for non-hospital patients is not included. For professional billing, only the following provided specialties are allowed:
| 01—General Practice |
38—Geriatric Medicine |
| 08—Family Practice |
42—Certified Nurse Midwife |
| 11—Internal Medicine |
50—Nurse Practitioner |
| 16—Obstetrics/Gynecology |
89—Certified Clinical Nurse Specialist |
| 37—Pediatric Medicine |
97—Physician Assistant |
Also, one of the following place of service (POS) codes is required on claims for G0472:
| 11—Physician’s Office |
49—Independent Clinic |
| 22—Outpatient Hospital |
71—State or Local Public Health Clinic |
Note that independent labs, specialty code 69 and place of service code 81, are not included on either list. Since the majority of screening tests will be done and billed by independent labs, the industry should seek clarification.
Diagnosis Codes Required
For those beneficiaries determined to be high-risk, ICD-9 diagnosis code V69.8, (other problems related to lifestyle) is required on claims in addition to G0472. Once ICD-10 is implemented, labs should use diagnosis code Z72.89 (other problems related to lifestyle).
For annual coverage when appropriate, the same ICD diagnosis code V69.8/Z72.89 will be included along with ICD-9 code 304.91 (unspecified drug dependence, continuous) or ICD-10 code F19.20 (other psychoactive substance abuse, uncomplicated).
For annual screenings, 11 full months must pass following the month of the last negative HCV screening.
Reason and Remark Codes
There are different claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs) that will be included on claims when services are denied. It is important for lab billing employees to be aware of what these codes mean so they can take the appropriate corrective action in the case of a denial. For instance, for institutional claims that are denied for TOB, the following codes should be included with the denial notice:
- CARC 170—Payment is denied when performed/billed by this type of provider.
- RARC N95—This provider type/provider specialty may not bill this service.
The transmittal defines specific CARCs and RARCs for each specific denial for both institutional and professional claims. Medicare summary notice codes are also included in the transmittal.
Further Clarification Needed
Another issue not clear in either of the transmittals concerns what tests are being performed and whether their HCPCS codes should be included on the claims. Here is what transmittal R174NCD says about the tests that should be used: “CMS will cover screening for HCV with the appropriate U.S. Food and Drug Administration (FDA) approved/cleared laboratory tests, used consistent with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement A[mendments] regulations.” The original decision memorandum says the following, “Initial testing for HCV should be performed using the most sensitive immunoassays licensed for detection of antibody to HCV (anti-HCV) in blood.” Further, there is no mention of reimbursement for G0472. This is another area where clarification is needed.
Actions Your Lab Should Take
The lab is dependent on the primary care physician to order the test correctly, and to document appropriately in their patient medical records.
The lab should make an educational contact with its customers concerning the requirements of the new benefit. Physicians should clearly identify the test as a hepatitis screening test and clearly indicate under which scenario the testing is being performed, either the once-in-a-lifetime or annual test. This will allow the lab to ensure the correct diagnosis information is included.
The laboratory should enter the new HCPCS code into their billing systems and include edits for the required diagnosis codes, TOB, specialties, and POS if their system allows. If not, you will need to develop some kind of manual process to make the determinations. If using a third-party billing company, make certain they include the codes and edits in their billing systems.
Since this is a screening test with a frequency limitation, the laboratory may collect advance beneficiary notices (ABN) on all Medicare patients. The communication should instruct ordering physicians to collect ABNs.
Labs should also contact their Medicare administrative contractor to seek clarification on the problem areas identified in this article. Document the call for future reference or to help with appeals and claims denials.
Phlebotomists, test entry employees, billing employees, and customer service employees should be educated about the new screening benefit and how to detect and report problems.
In addition, policies and procedures and annual compliance education and training material should be updated to help ensure compliance with the requirements of the new benefit.
Takeaway: There is a potential for an increased order volume for the new HCV screening benefit as Medicare beneficiaries become aware of it. Laboratories should become familiar with billing requirements to avoid potential compliance problems that may be associated with the screening. 