Update on Doctor Chart system.
The first pilot site for Doctor Chart at St. Luke's Midland is scheduled to be installed mid-January. Testing of the system at the pilot sites will occur before additional sites are brought online. Testing of the interface is ongoing for Doctor Chart at McKennan and Queen of Peace. Watch for further information as installation of the system continues.

Back to Top
Return to Index

Collection, Transport, and Processing of Blood Specimens for Coagulation Testing.
The current recommendations for collection, transport, and storage of specimens for blood coagulation testing are summarized by the National Committee for Clinical Laboratory Standards in the document, "Collection, Transport, and Processing of Blood Specimens for Coagulation Testing and Performance of Coagulation Assays" (H21 -A2).

The blood specimen may be obtained by venipuncture or from an indwelling catheter using an evacuated tube system or a syringe. If an evacuated tube system is used, the coagulation specimen should be the second or third tube obtained. Collect the coagulation specimen prior to the use of evacuated tubes containing any other anti-coagulant. If the blood must be drawn through an indwelling catheter, possible heparin contamination must be considered. The line should be flushed and the first specimen (at least 5 ml) discarded or used for other laboratory tests. In the case of any unexpected abnormal test result, a new sample should be obtained from a different location.

If the patient has a very high or low hematocrit, the citrate concentration of the evacuated tube must be adjusted. In cases of polycythemia (hematocrit >55%) the premeasured amount of citrate will be excessive for the reduced plasma volume and must be decreased. The coagulation time is lengthened and will progressively increase as the hematocrit rises. If the patient has severe anemia (hematocrit <20%) the premeasured amount of citrate will be inadequate for the increased plasma volume and must be increased.

Specimens that are clotted, hemolyzed, collected in the wrong tube, or are incompletely filled (<90% of expected fill) are not suitable for testing and should be rejected. Specimens that are lipemic or icteric may be unsatisfactory for most current instruments which use an optical detector.

The specimen should be transported to the lab and processed promptly. To obtain a plasma sample, the capped specimen is centrifuged at 2500 x g for 15 minutes. Carefully remove the plasma from cells, avoiding the buffy coat. The allowable time interval between obtaining the specimen and testing will depend on the temperature maintained during transport and storage of the sample:

• 22-24 C = 2 hours
• 2-4 C= 4 hours
• -20 C = 2 weeks
• -70 C = 6 months (rapidly frozen).

Coagulation factors such as V and VIII are labile and activity will be reduced if the specimen is improperly stored. If a specimen is to be frozen, it is recommended that the plasma be centrifuged a second time to create platelet-poor plasma (platelet count < 10,000). Freezing will lyse any remaining platelets and could cause normalization of an abnormal coagulation test.

Back to Top
Return to Index

Medicare Part A Updates.
New Panels: Beginning January 1, 1998, the AMA's CPT coding includes four new laboratory panel codes for frequently ordered profiles of automated- multichannel tests. The new codes are as follows:

Hepatic Function Panel A (with bilirubin, total and direct) - 80058

Basic Metabolic Panel - 80049

Electrolytes Panel - 80051

Comprehensive Metabolic Panel - 80054

There will be a three-month grace period through March 31, 1998, during which the old CPT automated panel tests (80002-19) may be billed. However, you may not bill both the old 80OXX codes and the new panel codes on the same claim. The temporary panel codes G0095-98 should not be used.

LMRP Updates: The following changes should be made to the Local Medical Review Policies:

82330-Ionized Calcium, add 275.40-275.49 and 780.31-780.39 as covered diagnoses.

83735-Magnesium, add 275.40-275.49, 780.31-780.39, 655.70, 655.71, and 655.73 as covered diagnoses.

84436-Thyroid testing, add 790.94 and 275.40-275.49 as covered charges.

Screening tests: Effective January 1, 1998, screening fecal-occult blood tests are covered at a frequency of once every 12 months for beneficiaries who have attained age 50. Coverage has been expanded for screening mammography to annual for women aged 40 and over, effective January 1, 1998. Prostate cancer screening, including digital rectal exams and PSA tests, will be added, effective January 1, 2000.

Please note: These updates are in effect for laboratory claims reimbursed by Medicare Part A, such as those submitted by Queen of Peace and St. Luke's Midland If you have any questions about the Medicare requirements for your laboratory orders, please contact the specific laboratory performing your testing.

Back to Top
Return to Index

Medicare Part B Updates.

Definition of Screening Vs. Diagnostic Tests. Although screening may be medically appropriate, it is not a Medicare benefit and not paid by Medicare. The clinician needs to distinguish between screening and diagnostic services.

Screening services are used to detect an undiagnosed disease where early prevention may prevent harm, and the patient has no signs, symptoms or history of the disease. Testing a preoperative patient for an undiagnosed disease that may increase operative risk and testing for a disease for which there is a family history are both, in the absence of symptoms, types of screening.

Diagnostic services are those used to manage a previously diagnosed disease or to evaluate symptoms in order to make a diagnosis. Testing a patient for an infectious disease when there has been a significant recent exposure to that disease is a diagnostic service.

Reasons for ordering a service or test:

1.  Symptoms. The patient's symptoms suggest a medical problem that cannot be resolved by the history and physical examination.

3.  Past History, including:

• past symptoms, no longer present, may require reevaluation
• past abnormal physical findings, no longer present, may require reevaluation
• the patient has a disease which may be asymptomatic, but requires periodic monitoring
• the patient is receiving some sort of therapy, drug or other, that requires periodic monitoring
• the patient is in the post-operative period of a diagnostic or therapeutic procedure, and the service is ordered to monitor progress or to assess possible complications

4.  Screening. None of the above conditions apply, but because the disease may have no early signs and early diagnosis may improve clinical outcome, a test to screen for the diagnosis is ordered.

5.  Liability. None of the above reasons may apply, but the physician may wish to limit liability and so performs the service.

6.  Error. The wrong test was ordered.

7.  Habit. The physician has always performed or offered this service.

8.  Faulty reasoning. The physician falsely believed that this test might have some bearing on the clinical picture.

9.  Curiosity. The physician or patient just want to know.

10. Patient demand. The patient demands a test be done on the belief that it may benefit him/her.

11. Financial gain. Because the provider gets paid for the service, even though none of the above apply, the service is performed.

Medicare considers only the first three reasons as meeting the requirements of "reasonably and medically necessary" and so qualifying for coverage. Although screening may be good medical practice, it is not covered by statute, with the exception of the screening mammogram and Pap smear.

With the Medicare necessity crack-down, having the right diagnosis and ICD-9 codes to justify testing is increasingly important. Healthcare providers should be educated and reminded that complete documentation of medical necessity is imperative for reimbursement of testing.

Please note.- These updates are in effect for laboratory claims reimbursed by Medicare Part B, such as those submitted by McKennan Regional Laboratory. The above information may or may not apply to laboratory claims that are reimbursed by Medicare Part A, such as those submitted by Queen of Peace and St. Luke's Midland If you have any questions about the Medicare requirements for your laboratory orders, please contact the specific laboratory performing your testing.

Back to Top
Return to Index

Question of the Quarter:

Q: How should I test gastric aspirate for pH and occult blood?

A: The Gastroccult test is a rapid screening test designed for detecting the presence of occult blood and determining the pH of gastric aspirate or vomitis. Identification of occult blood can be useful in the early detection of gastric trauma or deteriorating gastric condition' while pH may be useful in evaluating antacid therapy. Standard fecal occult blood tests lose sensitivity at low pH and may be unsuitable for use with gastric samples. The Gastroccult occult blood test is not affected by low pH, and is free from interferences by cimetidine (Tagamet), iron or copper salts. Most guiac-based products designed for use with fecal specimens are affected by these interferences, which are commonly encountered in gastric samples. Conversely, the Gastroccult test is not recommended for use with fecal samples.

The Gastroccult test is designed for use as a preliminary screening, and is not intended to replace other diagnostic procedures. As with any occult blood test, results cannot be considered conclusive evidence of the presence or absence of upper GI bleeding or pathology, and must be considered in light of clinical evidence and other diagnostic testing.