Saturday, June 19, 2010

HCPCS Modifier CF

HCPCS Modifier CF

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

Guidelines/Instructions:

  •  When submitting claims to Medicare for ESRD-related Automated Multi-Channel Chemistry (AMCC) tests, laboratories must identify which tests, if any, are not included within the ESRD facility composite rate payment. Submit HCPCS modifier CF to identify tests ordered by ESRD facilities or MCP

    1. physicians that are not part of the composite rate. (These tests are separately reimbursable.)

  •  This modifier may be submitted with the following CPT codes: 80048, 80051, 80053, 80076, 82040, 82247, 82248, 82330, 82435, 82465, 82550, 82947, 82977, 82495, 84460, 84478, 84550

More about the ESRD 50/50 rule:
  •  The ESRD 50/50 rule requires the billing laboratory to determine (for the same beneficiary on the same date-of-service):

  1.  The number of AMCC tests (ordered and performed) that are included in the composite payment rate paid to the ESRD facility (or the monthly capitation payment made to the furnishing physician); and
  2.  The number of covered non-composite tests paid

  •  The proportion of composite versus non-composite tests calculated by the billing laboratory is then used to determine whether separate payment may be made for all tests performed on that day

  •  Medicare's composite rate payment to an ESRD facility (or Monthly Capitation Payment (MCP) to a physician) includes reimbursement for certain routine clinical laboratory tests furnished to an ESRD beneficiary. However, separate payment for such clinical laboratory tests may be made when more than 50 percent of all Medicare-covered laboratory services (furnished to the same beneficiary on the same date of service) are AMCC tests that are not included in the composite payment rate.

  •  Laboratory tests subject to the 50/50 rule are those that are:
  1.  Included within AMCC tests, and
  2. Furnished to an ESRD beneficiary based upon an order by:
  •  A doctor rendering care in the dialysis facility; or
  •  A Monthly Capitation Payment (MCP) physician at the dialysis facility for the diagnosis and treatment of the beneficiary's ESRD

  •  Laboratory tests ordered by the MCP physician outside of the dialysis clinic are not subject to the ESRD 50/50 rule
  •  ESRD clinical laboratory tests identified with HCPCS modifiers 'CD', 'CE' or 'CF' may not be billed as organ or disease panels. Upon the effective date of CR3890, all ESRD clinical laboratory tests must be billed individually.
  •  For the same beneficiary, on the same date of service:
  •  When the 50 percent threshold is met [i.e., more than 50 percent of the covered tests are noncomposite payment rate tests] All laboratory tests (composite payment rate and non-composite payment rate tests) furnished on that date are separately payable.
  • When the 50 percent threshold is not met [i.e., 50 percent or more of the covered tests are
    included under the composite payment rate] No laboratory tests (including non-composite
    payment rate tests) furnished on that date are separately payable.
Note: A non-composite payment rate test is defined as any test separately reimbursable outside of the composite payment rate or beyond the normal frequency covered under the composite payment rate that is reasonable and necessary .


With respect to the application of the payment policy for AMCC tests for ESRD beneficiaries, the following applies:
  •  Payment is at the lowest rate even if those automated tests were submitted as separate claims for tests performed by the same provider, for the same beneficiary, for the same date of service
  •  For a particular date of service, the laboratory identifies the AMCC tests ordered that are included in the composite rate and those that are not included. The composite rate tests are defined by CMS.

  • All tests ordered for beneficiaries with chronic dialysis for ESRD must be billed individually. Palmetto GBA will reject claims for these tests when billed as a panel. Rejected claims must be corrected and submitted as new claims.

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