Author Topic: Denial for 86003 from Medicare  (Read 58 times)

kopietz

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Denial for 86003 from Medicare
« on: June 10, 2021, 01:42:19 PM »
We have a CLIA waived certificate.  An outside lab performs test 86003, but does not bill any insurance.  The lab bills us, and we bill the patient's insurance. 
We billed Medicare, but are getting denied.  Originally denied for incorrect # of units billed.  Most recently denied for CO-B7 with N570.  Patient did sign an ABN, a modifier GA was submitted.   We did not use a QW modifier.  All other insurances are paying us.
Can we not bill and get reimbursed from Medicare, and if not, why?
Can we still bill patient as we have a signed ABN even though it denied for a CO?


Michele

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Re: Denial for 86003 from Medicare
« Reply #1 on: June 10, 2021, 03:02:20 PM »
I believe the 86003 does not fall under the CLIA waived tests.  CLIA waived tests are "simple laboratory examinations and procedures that have an insignificant risk of an erroneous result."  If it is not a CLIA waived test it must be billed by a lab.
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kopietz

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Re: Denial for 86003 from Medicare
« Reply #2 on: June 10, 2021, 03:57:27 PM »
Can we bill the pt because we have a signed ABN?

RichardP

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Re: Denial for 86003 from Medicare
« Reply #3 on: June 10, 2021, 06:08:11 PM »
"If it is not a CLIA waived test it must be billed by a lab."

Just to avoid confusion here:

1.  An "outside lab" would be one that is a billing entity.  It has its own Taxpayer I.D. # and NPI number.  Billing is done under that Taxpayer I.D. and NPI number.

2.  A "Physician Office Lab" (POL) is NOT the billing entity.  The provider who owns that lab is the billing entity, and lab tests are billed under the Physician's Taxpayer I.D. # and NPI Number.  The POL must be certified for whatever level of testing it is doing above the designation of "CLIA waived".  This certification can cover everything an outside lab can be certified for.  But the POL is not an "outside lab".  This is a simplified generalization of a POL, but it serves to distinguish it from an "outside lab".

Both of these types of labs can bill for tests that are more complicated than "CLIA waived".

Michele

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Re: Denial for 86003 from Medicare
« Reply #4 on: June 10, 2021, 10:58:01 PM »
Sorry, I should have been more specific when I indicated "lab".  Richard is correct with his explanation.  I was just thinking of the situation you described in your question which is that the provider only had a CLIA waiver.

As for the ABN, the following article explains ABNs in detail.  https://www.cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf

I do not believe the ABN covers this situation because the service is a covered Medicare expense, but the provider isn't eligible to be reimbursed because is not certified to perform lab tests other than the CLIA waived ones.
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Re: Denial for 86003 from Medicare
« Reply #4 on: June 10, 2021, 10:58:01 PM »