CPT Overhauls Automated
Panels, HCFA To Hold Off January Startup
Get ready for a major shakeup of CPT
organ/disease panel codes, effective January 1, 2000. The CPT editorial board
has given final approval to a new automated panel for renal function, the addition
of one test each to three of the existing automated panels (basic and
comprehensive metabolic studies and hepatic function), and the creation of a
new panel for acute hepatitis. For the three revamped automated panels, new
codes have been assigned to replace those now in use. The fourth current
automated panel (electrolytes, CPT 80051) remains unchanged.
The
Health Care Financing Administration, however, is planning to delay Medicare
implementation of the new and revised automated panels until at least April,
though other CPT changes are expected to be adopted at the start of the new
year, according to Anita Greenberg in the division of acute care.
Local
Medicare contractors have told HCFA they will need the extra time to engineer
the systems changes necessary to process the new/revised panel codes and
install edits to prevent duplicate payments for panel tests. A HCFA program
memorandum to carriers and intermediaries, now being drafted for release soon,
is expected to instruct them not to pay claims using the new or revised
automated panel codes until these have been officially adopted by the agency.
Some surprises: CPT 2000 incorporates a number of
changes already reported by the National Intelligence Report (XX, 16/June 14, 1999,p.2), but also unfurls
some new developments, most notably the creation of a new 10-test renal
function panel (80069) and the elimination of existing thyroid panels 80091 and
80092. According to industry sources, the renal function panel was apparently
endorsed at the request of the dialysis industry, but it is not clear who
pushed to drop the thyroid panels. CPT may have done so, it is speculated, in
response to comments which surfaced during the lab negotiated rulemaking
marathon, question whether ordering multiple thyroid tests is consistent with
“good medical practice,” in light of the increasing specificity of thyroid
testing.
“Panel Creep”: The expansion of organ/disease
panels reflects, say informed sources, the preference of physicians for the
convenience of ordering tests in a panel, despite HCFA’s longstanding concern
over test utilization and medical necessity. Only two years ago, at HCFA’s
urging, CPT abolished the automated profile codes 80002-80019 (which had
figured prominently in Operation LabScam fraud settlements throughout this
decade) in favor of four smaller “clinically relevant” panels containing tests
on Medicare’s national roster of automated procedures. But the agency has
steadily tightened requirements for panels, in particular stipulating that for a
panel to be reimbursed, all its component tests must be medically justified.
CPT 2000: Highlights of Changes to Lab Test Panels
New Panel: Renal function panel (10 automated
tests) - consists of albumin, calcium, carbon dioxide, chloride, creatinine, glucose,
inorganic phosphorus, potassium, sodium, and BUN.
Acute
hepatitis panel - consists of Hepatitis A antibody, Hepatitis B core antibody,
Hepatitis B surface antigen, and Hepatitis C antibody.
Revised Panels: Basic metabolic panel - calcium
added to chloride, glucose, sodium, carbon dioxide, creatinine, potassium, BUN.
Comprehensive
metabolic panel - Alt added to almunin, calcium, chloride, glucose, potassium,
sodium, AST, total bilirubin, carbon dioxide, creatinine, alkaline phosphatase,
total protein, and BUN.
Hepatitic
function panel-Total protein added to albumin, total bilirubin, direct
bilirubin, alkaline phosphatase, ALT and AST.
Deleted: Thyroid panel & panel with TSH;
Hapatitis panel.
Source:
National Intelligence Report, Vol. XXI, No. 1/Oct. 8, 1999
CLIENT
SERVICES STARS
Kari
Davidson has worked
for Avera McKennan for 5 years, 4 of those in client services. Kari is a
graduate of Washington Senior High and the MLT program at Lake Area Vo-Tech in
Watertown, SD. Kari enjoys talking with and helping clients.
Kari
has two children, Kristin 18 and Matthew 8. In her spare time she enjoys
spending time with family and friends and collecting any type of pigs. She also
enjoys walking, hiking, camping, and sledding.
FROM
THE EDITOR...
Avera Queen of Peace has gone live with their Meditech blood bank
module. This allows for easier ordering and reporting of patient results.
As I
write this in early November, the temperatures are in the 60s and 70s. We have
included some fire safety reminders in this issue. Grass fires have been a
problem in much of the Midwest and remind us just how destructive fire can be.
The holidays are almost upon us and house fires are often frequent once the
Christmas decorations go up. Please be careful with decorations at home and
work. We don’t want to loose any of our extended network family.
December
31, 1999 is almost upon us. Preparations for Y2K compliance are in the final
stages around the Network. We’re confident that we’ll be well prepared for any
problems that may arise with the coming of the millennium. Remember that 2000
is a leap year as well, and February 29 may cause some computer problems in
older systems.
By the time you receive this
Thanksgiving will have passed, and Christmas and New Year’s Day will be fast approaching.
All of us at Lab News and around the
network wish you and yours a safe and blessed holiday season. See you in
2000!!!
INFLUENZA
ALERT
The flu season has started early
this year. The first case of the year in South Dakota was detected in the week
ending October 2, 1999. A 64-year old patient in Rapid City was admitted to
Rapid City Regional Hospital on 9-25-99 with fever, cough, dehydration, nausea
and vomiting. The patient had direct contact with a person experiencing a
febrile URI who had just returned from a one-week Alaskan cruise.
Outbreaks of influenza were reported
among tourists visiting Alaska and the Yukon Territory this summer. Influenza A
H3N2 Sydney-like virus has been identified as the cause of most of these
illnesses. Influenza A H3N2 Sydney-like is virus included in the vaccine for
the coming year.
Annual
vaccination is the primary method for preventing influenza. Persons who are at
high risk include person 65 or older and those under 65 with chronic underlying
medical conditions. Health care workers are encouraged to participate in
immunization programs.
DID
YOU KNOW…
Around 1000 AD, a Persian physician
named Ismail of Jurjani described seven different observations made on urine:
quantity, consistency, color, odor, transparency, sediment, and froth. During
the Middle Ages, the great painters typically showed physicians peering into a round
bottomed flask (called a matula) of urine. This practice became a common tool
of quacks and charlatans, who came to be known as “Pissa Prophets.” They not
only pretended to diagnose disease by visual examination of urine, but they
also claimed to see into the future.
Modern Urine Chemistry Manual, Bayer
Diagnostic
SAFETY
REMINDERS
Here are a few reminders to help
keep the upcoming holiday season safe. Remember never overload outlets, keep
electrical equipment (and holiday decorations) away from water sources, check
the cords on all holiday lights for damage.
Fire Safety: When operating a fire extinguisher
remember:
P—
Pull the Pin
A —
Aim at the base of the fire
S
— Squeeze the handle
S
— Sweep across the fire’s base
If you discover a fire remember:
R
— Rescue anyone in danger
A
— Sound the alarm
C
— Contain the fire
E
— Extinguish the fire or evacuate
the area
INFLUENZA
ASSAY OFFERED AT AVERA QUEEN OF PEACE
Beginning Monday, November 15, Avera
Queen of Peace Laboratory will begin offering Influenza testing. This procedure
detects both Influenza A and B, but does not distinguish between the two.
The
influenza assay will be done on an “as needed” basis. Sample of choice is a
nasopharyngeal mini-tip swab. Throat swabs and nasal aspirates are also
acceptable. (Note: Nasal washing are NOT acceptable.) Samples are stable for 24
hours at 2-8 c.
A
good sample is essential. The nasopharyngeal and throat swabs must be
vigorously rolled/rubbed against the mucosal surface. After insertion into the
transport system, the ampule must NOT be broken. If the ampule is broken the
test is invalidated. If a direct nasal aspirate is obtained, place it in a
sterile container for transport to the lab. The sample can not be diluted with
saline or water. Contact Avera Queen of Peace client services for further
details on collection and transport.
LOCAL
MEDICAL REVIEW POLICY UPDATES
Serum Iron Studies
Medicare
Part B Model Local Medical Review Policy
Description: Iron studies are used in the
evaluation of iron metabolism disorders, particularly iron deficiency and iron
excess.
Iron
deficiency is the most common cause of anemia. It is most often the result of
blood loss but may be secondary to iron
malabsorption. Classically, serum iron is decreased in iron deficiency but is
also low in acute and chronic inflammatory and neoplastic states.
Total
iron binding capacity (TIBC ) (83550), is an indirect measurement of
transferrin, a protein that binds and transports iron. It quantifies
transferrin in terms of the amount of iron it can bind and is reported as
percent saturation. TIBC is classically elevated in iron deficiency, pregnancy
and by agents that suppress ovulation. Because transferrin levels are depressed
in patients who are malnourished or who have chronic disease states, it may be
normal in patients who are iron deficient.
Because
of the significant limitations of serum iron (83540) and TIBC, serum ferritin
(82728) is a more accurate measure of storage iron. Low levels are unique to
iron deficiency while extremely high values are typical of iron storage
disease. Many chronic inflammatory, infectious, and neoplastic diseases are
characterized by moderate elevations in ferritin levels.
Indications and Limitations of
Coverage and/or Medical Necessity:
1. Iron studies are indicated in the
differential diagnosis of microcytic, hypochromic anemia as well as in iron
overload conditions.
2. Frequent repeat testing is not
necessary. Claims for frequent studies may result in denial or processing
delays in the absence of supportive medical documentation.
3. Covered diagnosis are listed in
the “Covered ICD-9 Codes” section of the model policy. It should be recognized
that the medical necessity for testing will be subject to review.
4. If a normal serum ferritin level
is documented, having been done for a covered sign, symptom, or disease, repeat
testing would not be medically necessary unless there is a change in the
patient’s condition verifying the need for repeat testing.
Reasons for Denial: Routine screening is not covered.
Submission for ICD-9 codes not listed in model policy will be denied. Automated
or manual calculations and/or extrapolated values will not be reimbursed
separately.
Note: The mere fact of linking a covered
diagnosis to a covered procedure does not support the medical necessity of the
procedure. Medical Necessity of the testing must be present and documented in
the ordering physician’s medical record.
Documentation Requirements: Documentation supporting the
medical necessity of these tests, such as ICD-9 codes must be submitted on the
claims. Failure to do so may result in denial of claim. The patient’s medical
record should contain notes documenting with relevant signs/symptoms or
abnormal laboratory results appropriate to the covered conditions. There must
be a physician’s order for each test documented in the patient’s medical
record.
CLARIFICATION: The August 1, 1999 Medicare
A Newsline indicated
that Troponin charges would be denied if any of the CK tests (82550-82554) were
performed. New study information supports the need for both results to
determine the underlying medical cause of chest pain. Therefore, both tests
will be covered within the scope of the Troponin (84484) Local Medical Review
Policy, retroactive to the policy effective date of June 21, 1999.
PERTUSIS
IN ADULTS AND
ADOLESCENTS
Pertusis or whooping cough is a
highly communicable respiratory disease that is traditionally seen in infants
and young children. The causative agent is Bordetella
pertussis. Paroxysmal cough with whoop, an elevated white blood cell count,
and marked lymphocytosis are considered hallmarks of pertussis infection in
children. There has been a resurgence of pertussis cases in young infants that
have not been fully immunized. There is evidence to suggest that adults serve
as a reservoir of infection for these children.
There
is speculation that currently, B
pertussis infections occur predominantly in adults and adolescents.
Clinical manifestations in adolescents and adults differ from those seen in
young children and adults; therefore, the occurrence in this population most
often goes undiagnosed. Persistent cough is the most common presentation among
teenagers. The perception that pertussis is only a disease of children remains
among clinicians as well as members of the community. Serologic evidence of
pertussis infection was demonstrated in 26% of college students with cough that
lasted for seven days or longer. Similar results were obtained in a study
conducted among adult patients who presented with cough as primary complaints
at the Emergency Department in Vanderbilt University Hospital. Other studies
also indicated that B. pertussis
infections in adults were common, endemic, and rarely recognized as pertussis.
The
specimen of choice to isolate B.
pertussis is a nasopharyngeal swab. For maximum recovery of these
organisms, two small calcium alginate or Dacron swabs on the end of a fine,
flexible aluminum wire are recommended. Cotton-tip swabs should be avoided
because cotton is inhibitory to the organism. To obtain adequate sampling,
swabs are placed at the site for at least 30 to 60 seconds to allow organisms
to be absorbed.
B. pertussis requires special growth culture
medium. Bordet-Gengou agar has been the classic medium to recover this organism
from clinical samples. In the late 1970’s Reagen-Lowe agar, a charcoal-based
agar with horse blood was introduced. Numerous studies have reported its
superiority over Bordet-Gengou. Regardless of the medium used, a nonselective
and selective medium must be used because certain strains of B. pertussis are susceptible to
methicillin or cephalexin.
Source:
The Resurgence of Pertussis: the 100-Day Cough, Connie R. Mahon; Clinical
Laboratory Science Sept/Oct 1999 Vol. 12/Number 5