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Apr 11th, 2019 - RNokes

Appropriate Modifier for 83615 @ 2 Units for CMS?

Hello,

Just curious if anyone has any input on how this should be coded.

83615 LDH x1
83615 LDH, MISC Fluid X1

CMS denial stating multi-channel lab not allowed. Any thoughts? MUE Error? Possible dx error? Mod Missing?

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Apr 24th, 2019 - ChrisW   130  1 

re: Appropriate Modifier for 83615 @ 2 Units for CMS?

The following information is from the Medicare Claims Processing Manual Chapter 16- Lab services found on Find-A-Code

40.6.1 - Automated Multi-Channel Chemistry (AMCC) Tests for ESRD Beneficiaries Rev. 3116, Issued: 11-06-14, Effective: 04-01-15, Implementation: 04-06-15)

Instructions for Services Provided on and After January 1, 2011 Section 153b of the MIPPA requires that all ESRD-related laboratory tests must be reported by the ESRD facility whether provided directly or under arrangements with an independent laboratory. When laboratory services are billed by providers other than the ESRD facility and the laboratory test furnished is designated as a laboratory test that is included in the ESRD PPS (ESRD-related), the claim will be rejected or denied. In the event that an ESRD-related laboratory test was furnished to an ESRD beneficiary for reasons other than for the treatment of ESRD, the provider may submit a claim for separate payment using modifier AY. The AY modifier serves as an attestation that the item or service is medically necessary for the dialysis patient but is not being used for the treatment of ESRD. The items and services subject to consolidated billing located on the CMS website includes the list of ESRD-related laboratory tests that are routinely performed for the treatment of ESRD.

I am also seeing a policy from Blue Cross stating “CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE”. This information was located under the Payer policies on Find-A-Code for a Medicare Advantage plan.

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