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CRIP Set 3
| Question | Answer |
|---|---|
| What is an independent laboratory? | A lab that is independent of a hospital that meets the requirements to qualify as an emergency hospital or is independent of an attending or consulting physician |
| What is a physicianed office laboratory? | A lab area in a physician's office that is maintained by the physician or group practice and is utilized to perform diagnostic tests |
| What is a clinical laboratory? | A lab that offers services to review microbiology, chemistry, serology, immunoassay, psychology, pathology, etc. The lab must be certified by CLIA unless the lab is exempt. |
| What do CLIA regulations establish? | Standards for lab testing performed on specimens from humans, such as blood, body fluid, and tissues, for the purpose of diagnosis, prevention, or treatment of disease or assessment of health. |
| What is a qualified hospital laboratory? | A lab that provides clinical lab tests 24 hours a day, 7 days a week to serve a hospital's emergency room that is also available to provide services 24 hours a day, 7 days a week. |
| What is the criteria to meet a qualified hospital laboratory? | The hospital must have physicians physically present or available within 30 minutes through a medical staff call roster to handle emergencies 24 hours a day, 7 days a week. It must also have hospital lab technologist on duty. Worm call at all times. Provide testing for the emergency room. |
| What is a referring laboratory? | A lab that receives a specimen to be tested and then refers the specimen to another lab for performance of the actual lab test. A referring lab must be Medicare approved. |
| What is a reference lab? | A lab that receives a specimen from a referring lab for testing and actually performs the test |
| What is a draw station? | A facility that collects specimens and sends them to a central lab but does not perform tests of any kind |
| If lab tests are performed in different departments on the same day, how many bills / claims should be submitted? | One |
| What is the date of service lab policy? | General- the dos of the test must be the date the specimen was collected Variation- if a specimen is collected already. That spans at least two calendar days, then the dos must be the date that the collection ended |
| What are the two exceptions to the lab dos policy? | Dos for test performed on storage specimens- is specimen store less than 30 days? The data service is the date the test was performed. If over 30 days date of service is the day it was obtained from storage. Dos for chemo sensitivity test which are performed on live tissue- dos of the test should be the date the test was performed |
| What does CMS define chemotherapy sensitive test? | A test that requires a fresh tissue sample to test the sensitivity of tumor cells to various chemotherapeutic agents |
| What are some types of lab panels? | Metabolic panel, comprehensive metabolic panel, renal function panel, lipid panel, electrolyte panel, hepatic function panel |
| If elab chooses to Bill each component of a panel test individually, how will payment be based upon? | The panel reimbursement itself, not individual test |
| What is reflex lab testing? | Reflex labs are perform subsequent to the initial lab test ordered for the patient. Used to further identify any type of significant diagnostic information that is deemed appropriate for the care of the patient. Two types of reflex testing protocols. Required, reflex test and optional reflex test |
| What is required reflex test? | Laptop switch if positive, require additional follow-up testing in order to have clinical value. The need for the follow-up testing should be implicit in the physician order. Any reflex tests required by the state, regulatory, or accreditation standards is considered to be a required reflex test. Example is a yarn culture reflecting an organism identification in sensibility. |
| What are optional reflex test? | Optional reflex lab tests occur when the initial test result may have a clinical value without the additional reflex testing. Example would be serum protein electrophoresis with monoclonal protein bands, with a reflex for band identification by serum immunofixation or immunoelectrophoresis? |
| What are the two types of mammography? | Screening and diagnostic |
| What is the age and coverage for screening mammogram for Medicare? | Under the age of 35- no payment allowed for screening mammogram Between ages 35- 39- will only allow one screening mammogram Over the age of 39- annual- annual is considered 11 full months after the month of the last screening |
| What are diagnostic mammograms? | To be considered diagnostic the criteria: Patient has signs and symptoms for which a mammogram is needed, patient has history of breast cancer, patient is asymptomatic but because of patients history and other factors, the physician judgment is that a diagnostic mammogram is appropriate |
| What are some billing considerations if a screening and a diagnostic mammogram are performed on the same patient on the same day? | You would add modifier GG stating Dad, the radiologist interpretation of the screening mammogram results in a diagnostic mammogram. Gigi would be applied to the diagnostic charge and the screening mammogram charge should be reported with a modifier 59. When both modifiers are appended they should pay. |
| What is a mammogram? | A direct x-ray of the breast. Sometimes a computer aided detection is performed as well. The cad procedure uses a laser beam to scan the mammography film from a film analog mammography and then converts it into digital Data for the computer. It then analyzes the digital Data for areas that may be suspicious for cancer. The patient is not required to be present for the cad process |
| What is digital breast? Tomosynthesis | A new screening and diagnostic brush imaging tool that is used to improve the early detection of breast cancer. The three-dimensional part of this service is able to take multiple images in seconds |
| If a screening CAD service is billed in conjunction with the springing mammogram and the screening, mammogram fails the age/frequency edits in the common working file, what happens with the claim? | Both of the services will be rejected |
| If a radiologist interprets a screening, mammogram , are they allowed to order and interpret additional films if needed? | Yes, as long as the beneficiary is still at the facility for the screening. Mammogram. If a radiologist interprets results in additional films being taken, the mammogram is no longer considered a screening exam. This can be done without additional order from the treating physician |
| If a screening mammogram requires additional images and turns into a diagnostic mammogram how is this considered in build? | The charges will be filled and paid for as a diagnostic mammogram instead of a screening mammogram. Since the original intent for the exam, however, was for a screening mammogram, for a statistical purposes, the claim is considered a screening. The claim should be billed to reflect a diagnostic revenue code of 0401 along with the appropriate CPT code in a modifier GG, which indicates a diagnostic mammogram converted from screening mammogram on same day |
| According to the national correct coding policy manual, how is fluoroscopy considered and how should it be billed? | |
| Unless specifically noted, fluoroscopy that is necessary to complete a procedure and obtain the necessary permanent radiographic record is included in the major procedure performed. It should only be reported when it is not included in the description of the primary procedure performed | |
| How should nuclear medicine be billed? | Any procedure requiring the use of radio labeled products should include the hcpcs code for the product on the same claim as the nuclear medicine procedure. Claim needs to reflect the date that each particular service was provided. So if the procedure was provided on a different dos from the radiolabled product there would be two different dos. Be sure to read the description to make sure the correct units are being billed |
| What are the guidelines for billing an MRI with an implanted pacemaker that is not approved for an MRI environment? | The claim must include specific items for the procedure code, diagnosis, code and modifier. The appropriate MRI procedure code Q0 modifier DX Code Z00.6- exam for normal comparison and control in clinical research program Z95.810- presence of an auto implantable cardiac defibrillator Z95.0 - presence of cardiac pacemaker Condition code of 30 for institutional claims only |
| What are the billing guidelines for an MRI with implanted pacemaker approved for MRI environments? | Mri procedure code Diagnosis code Z95.0 - presence of cardiac pacemaker KX modifier |
| What does PET stand for? | Positron emission tomography |
| What is a PET? | A non-invasive imaging procedure that assesses perfusion in the level of metabolic activity and various organ systems of the human body. They use a radioactive tracer substance such as a radio pharmacological fluorodeoxyglucose that is administered to the patient intravenously |
| When are PET scans covered? | They are only covered in a clinical situation in which the results May assist in avoiding other invasive diagnostic procedures or in the case where the result May assist the radiologist in determining the anatomical location to perform further invasive diagnostic procedures. |
| How are PET scans used to assist with staging rather than a diagnosis ? | Prior to the use of a PET scan, a tissue diagnosis is made |
| For a pet scan: restaging applies to testing after a course of treatment is completed and covered based on what? | After the completion of treatment for the purpose of detecting residual disease For detecting suspected reoccurrence or metastasis To determine the extent of a knowing reoccurrence If it could potentially replace one or more conventional imaging studies when it is expected that conventional study info is to determine the extent of a no one reoccurrence or if the study information is considered insufficient |
| Are PET scans covered for any other diagnostic uses were for screening purposes? | No |
| What does all PETscans require when they are performed | Radiopharmaological diagnostic imaging agent |
| What are two CPT codes for PET services along with their tracer CPT codes? | 78491 - myocardial imaging, PET, perfusion, single study at rest or stress 78492 - myocardial imaging, PET, perfusion, multiple studies at rest and or stress A9555 - Rubidium Rb-82, diagnostic, per study dose, up to 60 millicuries A9526 - Nitrogen N-13 Ammonia, diagnostic, per study dose, up to 40 millicuries |
| What tracer codes are reported for CPT codes? 78459, 78608, or 78811- 78816 or billed | A9552 - Fluorodeoxyglucose F18, FDG, diagnostic, purse study dose, up to 45 Millicuries A4641 - supply of radiopharmaceutical diagnostic imaging agent, not otherwise specified A9580 - Sodium Fluoride F-18, diagnostic, per study dose, up to 30 millicuries. Only applicable to CPT codes. 78811-78816 |
| If a radiologist, what are a blood sugar test? Is it billed separately? | No, it is included in the price of a pet scan |
| What does MNT mean? | Medical nutritional therapy |
| When is MNT covered under CMS? | Covered when services provided are furnished by a registered dietitian or a nutritional professional who meets certain requirements. This benefit is available for covered beneficiaries who have been diagnosed with diabetes or renal disease as long as a referral is made by a physician |
| What does CMS define diabetes as? | A condition of abnormal glucose metabolism diagnosed using the following criteria: a fasting blood sugar greater than or equal to 126 mgs/dl won two different occasions; a 2-hour post glucose challenge greater than or equal to 200 mg/dL, two different occasions; or a random glucose test over 200 mg/dl for a person with a symptom of uncontrolled diabetes |
| How does CMS define renal disease? | A chronic renal insufficiency or the medical condition of a beneficiary who has been discharged from the hospital or after a successful renal transplant within the last 36 months. Further classifies the definition as a reduction in renal function not severe enough to require dialysis or transplant |
| What are the benefits for MNT? | An initial visit for an assessment Follow up visits for any interventions that have taken place Reassessments that may be needed during the 12 month period beginning with the initial assessment date Totally separate from the diabetes self-management training benefits. Patients may receive both benefits in the same. Both the DSMT and MNT are not allowed to be billed on the same dos for the same beneficiary |
| What are the MNT coverage guidelines? | 3 hours of one-on-one counseling one on one the first year in 2 hours in all subsequent years. Every calendar year must have a new referral for an additional follow-up hours Referral can only be made by the treating physician and when the patient is diagnosed with diabetes or renal disease Additional hours may be covered if there is a change in diagnosis or medical condition that makes a diet change necessary |
| What requirements must be met for screening PAP smears. | -Ordered and collected by authorized provider. - pt must not have had PAP within last two years -Screening dx code -Doc in chart confirm, pt is childbearing age, exam that indicates cervical or vaginal cancer, or abnormalities within last 3 years. -High risk for vaginal or cervical cancer. - |
| What is considered high risk for cervical or vaginal cancer? | Sexual activity began 16 or younger More than 5 partners History of STD Having less than 3 neg/Pap smears withing the past 7 years Daughters of women who took DES (diethylstibestrol during pregnancy. |
| What legislation provide screening coverage for a screening pelvic and breast exam? | The Balance Budge Act of 1997 |
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