MLN Matters® Number: MM6683
Related Change Request (CR) #: 6683
Related CR Release Date: October 30, 2009
Effective Date: Claims processed on or after April 5, 2010
Related CR Transmittal #: R586OTN
Implementation Date: April 5, 2010
Provider Types Affected
This article is for physicians, laboratories, and providers billing Medicare contractors (carriers or Medicare Administrative Contractors (MACs)) for Automated Multi-Channel Chemistry (AMCC) ESRD-related tests provided to Medicare beneficiaries.
Provider Action Needed
You should be aware that CR 6683 creates the functionality in the Medicare systems to check that claims for Automated Multi-Channel Chemistry (AMCC) ESRD-related tests for an ESRD beneficiary ordered by a physician from the dialysis facility use the ESRD 50/50 rule modifiers properly. Claims validation will begin with claims processed on or after April 5, 2010.
Make sure that your staff is aware of this validation process.
Background
CR 6683 advises that, effective with claims processed on or after April 5, 2010, Medicare will validate claims for AMCC ESRD-related tests provided to a beneficiary who is ESRD eligible to ensure your compliance with billing instructions regarding the use of the ESRD 50/50 rule HCPCS modifiers CD, CE, and CF.
The payment of certain ESRD laboratory services performed by an independent laboratory is included in the composite rate calculation for ESRD facilities. When billing Medicare for AMCC ESRD-related tests, laboratories must indicate which tests are or are not included within the ESRD facility composite rate to ensure proper reimbursement.
The ESRD 50/50 rule classifies AMCC ESRD-related tests according to the following categories:
- AMCC test ordered by an ESRD facility (or a physician included in the monthly capitation payment (MCP), i.e., an MCP physician) that is part of the composite rate and is not separately billable;
- AMCC test ordered by an ESRD facility (or MCP physician) that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity; and
- AMCC test ordered by an ESRD facility (or MCP physician) that is not part of the composite rate and is separately billable.
When billing for AMCC ESRD-related tests, the laboratory must include the appropriate modifier for each test, as follows:
- HCPCS modifier CD – AMCC test has been ordered by an ESRD facility (or MCP physician) that is part of the composite rate and is not separately billable;
- HCPCS modifier CE – AMCC test has been ordered by an ESRD facility (or MCP physician) that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity; or
- HCPCS modifier CF – AMCC test has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable.
The proportion (or percentage) of composite tests to non-composite tests billed is used to determine whether separate payment may be made for all tests performed on the same day for the same beneficiary. The chart attached to CR 6683 identifies the AMCC ESRD-related tests and the Web address for accessing CR 6683 is provided in the “Additional Information” section of this article.
Physicians, providers, and suppliers billing AMCC ESRD-related tests to Medicare must report CD, CE, or CF HCPCS modifiers for each test. If at least one of the three HCPCS modifiers is not shown for one of the AMCC ESRD-related test codes, all AMCC ESRD-related tests on the claim will be returned as unprocessable. When an organ disease panel (i.e., CPT codes 80076, 80047, 80048, 80053, 80069, 80061, or 80051 in the chart attached to CR 6683) is billed on a claim regardless of whether CD, CE, or CF HCPCS modifier is used, the claim will be returned as unprocessable.
If the beneficiary is not ESRD eligible or if the ordering physician is not an MCP physician, then the Medicare contractor will process the claim as acceptable and payable as a non-ESRD claim.
Additional Information
The fact sheet, Outpatient Maintenance Dialysis End-Stage Renal Disease, provides general information about outpatient maintenance dialysis for End-Stage Renal Disease, the composite payment rate system, and separately billable items and services. The fact sheet is available at http://www.cms.hhs.gov/MLNProducts/downloads/ESRDpaymtfctsht08-508.pdf on the CMS website.
If you have questions, please contact the Palmetto GBA Provider Contact Center at our toll-free number, (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.