A Complete Guide to CMS Guidelines: How CureCloudMD Simplifies Laboratory Billing Solutions

Introduction to CMS

The Centers for Medicare and Medicaid Services (CMS) is an independent agency of the US Department of Health and Human Services (DHHS). This federal agency handles the Medicare and Medicaid programs providing health coverage to millions of Americans.

CMS provides clear laboratory billing guidelines that all laboratories must follow. These guidelines ensure proper payment for healthcare professionals and help laboratories maximize their profitability.

What are CMS Guidelines?

The CMS set guidelines for laboratory billing to ensure accuracy and timely reimbursement for healthcare institutions.

These guidelines cover key areas like;

• Medical billing
• Coding
• Claim Submission and Reimbursement.

Keep reading to learn how these CMS laboratory billing guidelines can improve laboratory billing’s revenue cycle management (RCM).

CMS Guidelines for CLIA Certification Requirements

Clinical Laboratory Improvement Amendments (CLIA) are applied by federal standards to all laboratory testing services in the U.S. This means that laboratories must have CLIA certification to test human samples. Each laboratory must meet specific regulations depending on the type of testing.

Different types of CLIA certificates are available including;

1. Certificate of Waiver – for simple test with low-risk results
2. Certificate of Compliance – for moderate as well as high complexity tests.

CMS Guidelines for Laboratory Billing Codes

Proper coding of services is crucial in laboratory billing services. Appropriate codes must be used to describe the type of laboratory procedures performed at a particular time. CMS has several code sets that include the following:

1. CPT Codes – Current Procedural Terminology Codes used for medical, surgical, and diagnostic procedures.
2. Healthcare Common Procedure Coding System (HCPCS) Codes – used for Medicare and Medicaid billing for services that are not represented by the CPT code set.
3. International Classification of Diseases (ICD-10) Codes – A system of describing a patient’s condition or diagnosis.

CPT Codes for Laboratory Billing Services

• CPT Codes 80047-80076 are used for General pathology and laboratory services
• CPT Codes 81000-81099 are used for Urinalysis tests
• CPT Codes 82000-82738 are used for Chemistry and blood tests
• CPT Codes 83001-84999 are used for Immunology and infectious disease tests
• CPT Codes 85002-85999 are used for Haematology and blood tests
• CPT Codes 86000-86999 are used for Serology and microbiology tests
• CPT Codes 87001-87999 are used for Cultures, infections, and virology testing
• CPT Codes 88000-88099 are used for Cytopathology and other microscopic testing
• CPT Codes 88104-88199 are used for Pathology and lab services for cancer testing
• CPT Codes 99000-99099 are used for Miscellaneous laboratory services

CMS Guidelines for National Correct Coding Initiative (NCCI)

CMS created the National Correct Coding Initiative to promote proper coding practices in laboratory medical billing.

The NCCI laboratory billing guidelines contain specific CPT pair codes that help in identifying those specific procedures that should not be billed together. For laboratory billing, this could mean that there are tests that get bundled and healthcare professionals are supposed to know the bundling rules in order to submit clean claims.

What are Modifiers?

Modifiers are two-character codes added to the main CPT or HCPCS code to provide additional information about the service. Three common modifiers utilized in laboratory billing include the following;

1. Modifier 91 – Some laboratory tests are performed by the same method on the same day.
2. Modifier 59 – A code is reported to indicate a procedure or service that is distinct from other services performed on the same day.
3. Modifier QW – Used for tests waived under CLIA certification.

Correct usage of the modifiers ensures effective processing of the claims without any misconception in the billing process.

CMS Guidelines for Advance Beneficiary Notification (ABN)

An Advance Beneficiary Notice is given to Medicare patients, prior to the service delivery, if there is a certainty that Medicare may not cover the service. The ABN allows the patient to decide whether to proceed with a service for which they could be held responsible for payment.

Significance of ABN

ABN is mandatory in laboratory billing services when performing a test that does not meet Medicare requirements. It needs to be given to the patient prior to the service along with his signature.

CMS Guidelines for Medicare Clinical Laboratory Fee Schedule

The Clinical Laboratory Fee Schedule is a tool CMS uses to set payment rates for laboratory services. This schedule is updated annually with fee increases based on the percent of change in the Consumer Price Index.

This fee is applicable to all laboratory medical billing practices and includes the test payment amounts that will be effective for the calendar year. Healthcare professionals will refer to the CLFS for billing purposes to ensure the appropriate amount is charged for their services.

CMS Guidelines for Documentation in Laboratory Billing

Credible documentation is a key to success in the laboratory billing services. Healthcare professionals should justify the presence of the tests in a medical record. The medical record should contain, in part;

1. Physician’s Order – Lab test ordered by a licensed provider.
2. Patient’s Diagnosis – Corresponding diagnosis code supports medical necessity.
3. Test Results – The results are documented in the patient’s record.

If the documentation is incorrect, the claims may be denied, and the provider may be subject to an audit or penalty from CMS.

CMS Guidelines Denials and Appeals

Laboratory billing is complicated and may be denied for various reasons. Some common causes for claim denials are below;

• Incorrect coding
• Lack of substantiation for medical necessity
• Lack of documentation
• Duplicate billing

Healthcare professionals should have a process in place to handle the denials. This includes

• Working on the denial reason
• Correcting errors
• Filing an appeal (if required)

All appeals must be filed within the specific timeframe established by CMS with supporting documentation being a necessity.

What are MACs?

Medicare Administrative Contractors (MACs) are private companies subcontracted to process Medicare health claims under the CMS. Each MAC is area-based and issues instructions regarding how to submit a claim.

Hence, a provider must be fully aware of the rules of his specific MAC and submit the claims as required. MACs also support audits, and appeals and provide education. Healthcare professionals can reach their MAC with questions or needs or to address a concern or disagreement on a claims processing decision.

CMS Guidelines for Quality Payment Program (QPP)

CMS proposed a reform in health care delivery and payments by introducing the Quality Payment Program (QPP) that helps make laboratory billing services better and more affordable.

Starting in 2017, the QPP began adjusting Medicare payments based on how well clinician’s group practices, and other eligible participants meet specific quality measures. Healthcare professionals are incentivized if certain standards are met, such as measures of appropriate usage of laboratory services, under the MIPS program.

Laboratory service providers must show their performance based on quality measures like;

• Accurate documentation
• Timely reporting
• Clean claim submission

These quality measures, if achieved, can result in positive payment adjustments, while failure may lead to penalties.

Medicare Part B Laboratory Services Coverage

Most of the laboratory services are covered under Medicare Part B if they are a medical necessity and prescribed by a doctor or any other healthcare provider. The tests must fulfill the following criteria:

1. The test has to diagnose or treat the patient’s medical condition.
2. The facility providing the service has to be a CLIA-certified laboratory.
3. The test has to be on the list of covered services by Medicare.

Medicare Part B does not usually cover laboratory tests that are routine or not medically necessary.

Preventive Services Billing

Medicare Part B also covers preventive laboratory services without the need for a deductible and coinsurance. Such services are supposed to avert illnesses. Some common preventive lab services include the following:

1. HIV Screening: At-risk screening services are available.
2. Diabetes Screening: Risk-factor screening is available.
3. Cholesterol Testing: This service is covered for heart disease risk.

This requires that these tests adhere to the criteria established by CMS for preventive services if they are to be reimbursed without cost sharing by the patient.

Role of Curecloudmd and CMS Laboratory Billing Guidelines

CureCloudMD helps laboratories comply with the rules and regulations for laboratory billing services set by CMS. These rules must be followed when a laboratory service provider submits a bill and wants it paid.

CMS guidelines can be challenging due to the variety of laboratory services performed at different stages of treatment. The technical expertise of Curecloudmd will definitely reduce the risk of errors.

How Does Curecloudmd Assist Healthcare Institutions?

Curecloudmd can assist the healthcare institutions and the patients in the following ways;

Accurate Coding

Laboratory billing services require correct coding and Curecloudmd hires expert coders with the complete knowledge of CPT, HCPCS, and ICD-10 codes. They make sure that healthcare professionals use the right codes and thus, reduce probable denials in claims.

Moreover, Curecloudmd utilizes reputable softwares like CareCloud Central and eClinicalWorks that help in submitting accurate CPT codes for laboratory billing services.

Compliance with HIPAA guidelines

CMS requires laboratory services to comply with HIPAA rules and guidelines that are updated every year. So, it becomes quite challenging for the laboratories to remain compliant with all the updates.

However, Curecloudmd helps laboratories ensure that their laboratory tests consistently meet HIPAA requirements.

Proper Documentation

Proper Documentation is a part of medical billing compliance and it is directly responsible for profitability of a laboratory medical billing. Curecloudmd helps healthcare organizations in maintaining all records accurately that contain the reason for conducting the test and the results. It also prevents the mistakes that may lead to denials of claim settlement.

Submit Claims on Time

Curecloudmd ensures to submit the claims to Medicare and Medicaid within time limit. This helps healthcare professionals to get paid faster without any probable delay. Also, it helps the company to boost their revenue cycle management (RCM).

Prevention from Billing Errors

Curecloudmd helps the health institutions in avoiding common mistakes of medical billing and coding. These may include double billing or inaccurate coding. Company reviews all the claims before they are submitted to catch the errors, if any.

CLIA Compliances

All the laboratories must comply with the rules and regulations of Clinical Laboratory Improvement Amendments (CLIA). Curecloudmd utilizes the best laboratory billing software and experienced billing professionals to meet the requirements of CLIA.

Continuous Customer Support

Curecloudmd helps healthcare professionals and patients stay compliant 24/7 with all the CMS standards regarding laboratory billing services. It always remains up to date with the latest laws and regulations. The primary compliance support services include

• Ongoing audits
• Training
• Education to ensure that all billing activities are conducted as per the cms guidelines.

Wrapping up!

CMS billing services are the only way by which healthcare professionals will bill their laboratory services with confidence after understanding the critical elements that make up such guidelines, including the CPT coding system, proper documentation, and compliance with HIPAA guidelines.

Furthermore, compliance with CMS guidelines improves the quality of laboratory medical billing service, allows laboratories to be paid fairly and on time and the health professional to spend less time managing the medical facility.