Railroad Medicare Drugs of Abuse Testing Webcast: Questions and Answers

The following questions were received during our June 12, 2018, webcast.

Q: Where can I find the regulation on the UDT must be ordered by the provider who is treating the patient for a specific medical program?

A: We will refer you to the MLN "Complying with Documentation Requirements for Laboratory Services" document, which states, "The physician who is treating the beneficiary must order all diagnostic X-ray tests, diagnostic laboratory tests, and other diagnostic tests.

"The physician who treats the beneficiary is the physician who furnishes a consultation, treats a beneficiary for a specific medical problem, and uses the results in the management of the beneficiary’s specific medical problem. Tests not ordered by the physician are not reasonable and necessary."

The Code of Federal Regulations for that would be 42 CFR section 410.32(a) for ordering diagnostic tests and 42 CFR section 410.32 (d) 2(i) which is the medical necessity section.


Q: Why is the laboratory held responsible for the physicians quality of documentation when we are not present or in any way able to assist in guidance to tell how well the practitioner documents? We perform the testing at the request of the provider, based on their relationship with their patient. They are the professional and know their patients best.

A: The MLN "Complying with Documentation Requirements for Laboratory Services" document states "If you bill laboratory services to Medicare, you must obtain the treating physician’s signed order (or progress note to support intent to order) and documentation to support medical necessity for the ordered service(s). These records can be housed at another location (for example, a nursing facility, hospital, or referring physician office)."

Addendum: After a call to the lab group posing this question, we want to add to this answer.

In the presentation (slide 12) we present the Social Security Act, Title XVIII, section 1862. This Act establishes a law of medical necessity. The direct statement is “no payment may be made under part A or part B for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

If the documentation does not contain substance to support the service is "reasonable and necessary," by law, Medicare cannot pay for the service. Since the laboratory provider billed and received payment, Medicare funds are recouped from the lab.


Q: Can you elaborate on the Case Study #5 (slide 43) on Drug Panel 4? Would this result in denial in payment?

Case Study 5: Order for Panel or Specific Tests

A: In this case study, the order for Drug Panel 4 shows how orders for tests are often submitted to our medical review department.

In test selection one, the provider simply orders "Drug Panel 4." This notation is not sufficient, as it fails to identify which drugs are included in this panel. This type of order could result in a denial.

If a provider has set up a drug panel with a laboratory, the documentation provided for review should contain an agreement form from the provider that must identify the individual tests that are included in the panel. For example, if we were to use the example on this slide, the provider’s agreement form could state, “Drug panel 4 is to include THC, cocaine, opiates, and methamphetamine.” An agreement form, such as this, would be taken into consideration during the medical review process.

Regulations require that all tests must be ordered by the provider treating the patient. Ordering "Drug Panel 4" is not a statement that supports which specific tests the provider wants to include. A "Drug Panel 4" at one lab may not be the same at another lab.

The second test selection on the slide shows how tests are listed individually on the requisition form. If an order for tests is submitted this way, it would not require a provider’s explanation form of preset drug panels.


Q: Is Palmetto GBA starting a targeted review on urine drug testing?

A: The Targeted Probe and Educate review is provider-specific. There will be some testing done on that. This postpayment review is being done as service-specific.

Q: What was the course number?

A: The Railroad Medicare course number that you can use on your certificate of attendance is RRB1675354.

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