Laboratory Alliance of Central New York, LLC: lab, laboratory, laboratory alliance, laboratory alliance of central new york, laboratory alliance of cny, syracuse, central new york lab, syracuse area laboratory, liverpool area laboratory, liverpool, liverpool new york, ny, allergy, upper respiratory disease testing, chemistry, coagulation, cytology, emergency toxicology, hematology, histology, immunology, microbiology, mycobacteriology.

BILLING POLICIES

Medical Necessity / Diagnosis Codes

Every third party bill must have a valid diagnosis code (ICD-9 Code). Please be sure to supply the appropriate diagnosis or diagnosis code for the patient’s condition on the specified date of service on the laboratory requisition.

Medical Necessity is defined by the Medicare Part B Carrier as those tests and services that it determines to be “reasonable and necessary”. The Part B Carrier may develop “local coverage determinations” (LCD’s) for specific tests. In addition, in November 2002, the Medicare National Coverage Determinations (NCD’s) became effective. The NCD’s for laboratory tests are similar to the local LCD’s already in existence. There are 23 NCD’s that became binding on all laboratories. The NCD and the LCD indicates which diagnoses, signs, or symptoms are payable for these specific tests. If a test is ordered in which a local medical review policy or a national coverage decision exists, there must be appropriate diagnosis codes for that test, otherwise, Medicare will deny payment. When ordering a test that does not meet a local medical review policy or a national coverage decision, an Advanced Beneficiary Notice (ABN) must be obtained from the patient. The purpose of the ABN is to give the patient advance notice that Medicare may not pay for the test ordered.

We encourage you to take note of and regularly visit the following two Web sites for the most current information about the LCD’s and NCD’s. Changes are sometimes made to the policies and coverage determinations on a quarterly basis.

For LCD information: www.umid.nycpic.com/lcd.html

For NCD information: www.cms.hhs.gov/coveragegeninfo/downloads/manual4/pdf

Tests Covered by the National Coverage Determinations (NCD)

· AFP

· CBC

· CA 15-3

· CA 19-9

· CA 27.29

· CA-125

· CEA

· Collagen Crosslinks (N-Telopeptide)

· Culture, Urine

· Digoxin

· GGT

· Glucose Testing

· HCG, Quantitative

· Hemoglobin A1C

· Hepatitis Panel, Acute

· HIV Testing, Diagnosis

· HIV Prognosis, including Monitoring

· Iron Studies:

Ferritin

Iron

IBC

Transferrin

· Lipid Testing (Lipid Profile, including Cholesterol)

· Occult Blood

· PSA- Monitor

· PT

· PTT

· Thyroid Testing:

Free T4

TSH

Thyroid Hormone (T3 or T4) Uptake or THBR

Tests Covered by the Local Coverage Determinations (LCD):

· Allergy (Rast Test)

· B-Type Natriuretic Peptide (BNP)

· CRP, High Sensitivity

· Drug Screening

· Erythrocyte Sedimentation Rate (ESR)

· Flow Cytometry

· Helicobacter Pylori Tests

· Hepatitis Tests (Hepatitis B Surface Antigen, Hepatitis B Core Antibody, Hepatitis B Surface Antibody, Hepatitis C Antibody)

· Immunochemistry Stains

· Ionized Calcium

· Magnesium

· Parathyroid Hormone (PTH)

· Pap Smear

· Prostatic Acid Phosphatase (PAP)

· Troponin

Tests Covered by Medicare on a Defined Frequency

Screening Pap Smears:

Medicare covers one screening Pap smear every two years, and more if the beneficiary falls into one of the following categories:

Patient is of childbearing age and has had an exam indicating the presence of cervical or vaginal cancer or other abnormality during any of the preceding three years;
Patient is considered to be at high risk for vaginal cancer as evidenced by prenatal exposure to diethylstilbestrol or for cervical cancer as evidenced by any of the following:
- Early onset of sexual activity (under 16 years of age),
- Multiple sexual partners (five or more in a lifetime),
- History of a sexually transmitted disease (including HIV),
- Fewer than three negative, or no Pap smears within the previous seven years.

Screening Fecal Occult Blood Tests:
Medicare covers fecal occult blood tests on asymptomatic patients once every 12 months for individuals who have attained age 50.

Screening Prostate Specific Antigen (PSA):
Medicare covers a screening PSA once every 12 months for male individuals who have attained age 50.

Cardiovascular Screening Tests:
Cardiovascular Screening Tests (cholesterol, HDL, Triglycerides) – is covered once every five years.

Diabetes Screening Tests:
Diabetes Screening Tests (Glucose, 2Hr PP) – covers: a ) Two screening tests per calendar year for individuals diagnosed with pre-diabetes; b) One screening test per year for individuals previously tested who were not diagnosed with pre-diabetes, or who have never been tested.

Health Insurance Portability and Accountability Act (HIPAA)

Laboratory Alliance of CNY is committed to protecting the confidentiality of individual’s laboratory test results and other patient protected health information (PHI). Laboratory Alliance has adopted policies and procedures that comply with the Health Insurance Portability and Accountability Act (HIPAA) regulations. Training of employees was completed in April 2003. If you should have any questions concerning the privacy or confidentiality of PHI please contact:

Privacy Officer

Laboratory Alliance of CNY, LLC

1304 Buckley Road

Syracuse, New York 13212-4302

Telephone: (315) 453-7200
Fax: (315) 461-3030

Professional Courtesy

Professional courtesy testing is prohibited as stated in the Corporate Compliance Plan of Laboratory Alliance of Central New York, LLC.

Standing Orders

Laboratory standing orders are permitted as long as Laboratory Alliance receives a written order that includes duration, frequency, diagnosis and a physician signature. Written requests for standing orders need to be renewed by the physician every 6 months.

Reflex Testing

Reflex testing is testing that is performed as a result of initial test results which are used to further identify significant diagnostic information required for appropriate patient care. The following is a list of the tests for which Laboratory Alliance may perform reflexive testing:

Chemistry/Immunology:

· ANA with Reflex - When the result of an ANA screen is positive, an ANA Evaluation
Panel will be performed. The panel is composed of the following analytes: Anti-dsDNA, Anti-SSA, Anti-SSB, Anti-Smith, Anti-SmRNP, Anti-RNP, Anti-Chromatin, Anti-Scleroderma, Anti-Centromere B, Anti-Ribosomal P and Anti-Jo-1 (IgG antibodies).

· Syphilis Screen - If the result of a syphilis screen is positive, a secondary test will be performed.

· Protein Electrophoresis - If an abnormality is identified on a protein electrophoresis, an Immunofixation is performed. Note: If reflex testing is not desired, order “Protein Electrophoresis – No Reflex”.

· Lyme Antibody – When the test for Lyme IgG/IgM is positive or borderline, a confirmatory test will be performed.

· Toxoplasma IgG/IgM – When the test for Toxoplasma IgG/IgM is positive; Toxoplasma IgM will be performed.

· HIV-1 Antibody – When the result of HIV-1 Antibody test is positive, a confirmatory test will be performed.

· Lipid Panel – When the result of triglycerides is greater than 250 mg/dL, a direct LDL is performed.

· Hep C Virus Ab – When antibody screen is positive and the signal/cutoff ratio is less than 8.0, a Hep C Virus Ab RIBA confirmation test is performed.

· PSA with Reflex to Free – When the result of the Total PSA is greater than 3.9 ng/mL and less than 10.1 ng/mL, a free PSA is performed.

· Thyroid Cascade – If the TSH is abnormal, a Free Thyroxine is performed. If Free Thyroxine is normal, then a Free T3 is performed.

Hematology:

· Platelet Count – If an automated platelet count cannot be obtained, a manual platelet count will be performed.

· Peripheral Smears – Peripheral smears and body fluids will be reviewed by a pathologist when indicated.

· White Blood Count – A manual white blood cell count may be ordered and performed if the automated white blood count cannot be resulted.

· Hematocrit – A hematocrit may be ordered on a patient with the reticulocyte count test if the patient has not had a hematocrit or complete blood count performed within the previous eight hours. The hematocrit result is necessary to obtain a portion of the test result.

· Bone Marrow –A CBC/Diff and reticulocyte may also be performed.

· Lupus Anticoagulant –The following tests may also be performed when this test is ordered:

· Dilute Russell Viper Venom – confirm and ratio

· APTT Mixing Study

· Dilute Russell Viper Venom Screen Mixing Study

· Dilute Russell Viper Venom Confirm Mixing Study

Microbiology:

· Organism/Susceptibility Testing –If an organism is isolated, there may be additional
identification and susceptibility testing done.

· Group A Strep Screen – When the results of a Group A Strep Screen are negative, a culture is done to confirm the negative.

· Ova & Parasite Exam – Positive specimens may have an additional charge for special stains.

· Viral Cultures – Additional charges for identification or screening for respiratory viruses may be added.

Transfusion Services:

· Antibody Identification – is automatically performed if the antibody screen is positive unless the clinician indicated that further testing is not desired.

Urinalysis:

· Urine Microscopic – A urine microscopic analysis is performed when an abnormality on the screening examination is detected.

PARTICIPATING THIRD PARTY PAYORS

Aetna
American Progressive
Arcadia Health Plan
Beechstreet
Blue Cross & Blue Shield (BC/BS) All products
CDPHP
Champus
Choice Care (Humana)
Cigna
EBS Benefit Solutions
Empire Plan (UHC)
Evercare (UHC)
Fidelis
GHI
HealthNow
HMO CNY (BC/BS)
HMO Blue (BC/BS)
Magnacare
Medicaid
Medicare
Metracomp
MVP
North American Administrators
National Preferred Provider Network (NPPN)
PHCS
POMCO
Railroad Medicare
RMSCO
Statewide PPO
Total Care
Touchstone Health Partnership
United Healthcare (All Products)
Univera PPO (Excellus)
Upstate Administrators
Wellcare

Note: Laboratory Alliance is also a member of UNYHEALTH. Please refer to the Laboratory Alliance web-site www.laboratoryalliance.com for the most current list of third party payors.

Current as of August 2009