March 8, 2021
Part A Medical Review Findings: Laboratory Service Billing Errors
Findings
Multiple laboratory service billing errors have been identified by CGS’ Medical Review Department and the Comprehensive Error Rate Testing (CERT) Contractor.
Billing/Coding Must Reflect Only Service(s) Ordered
To help increase the accuracy of submitted claims, ensure the billing and coding of your claims reflect only the service(s) ordered by the physician or qualified non-physician practitioner (NPP). Additional laboratory tests that are billed and not ordered by the beneficiary’s treating practitioner are not reimbursed by Medicare. Standard protocols that may exist within your facility to bill a specific code for an ordered service(s) are not accepted as orders by Medicare. Any additional billed service(s) must be indicated in the physician order to receive payment.
Prevent Common Billing and Coding Errors
Example 1:
If the physician has ordered a Complete Blood Count (CBC), the claim should only be billed with CPT code 85027 (CBC automated without differential).
CPT code 85025 (CBC with automated White Blood Count (WBC) differential) should not be billed.
The physician only ordered a CBC, so an automated WBC differential should not have been included and will not be reimbursed by Medicare.
Example 2:
If the physician has ordered a Urinalysis Screen, the claim should only be billed with CPT code 81003 (Urinalysis without microscopy).
CPT code 81001 (Urinalysis with microscopy) should not be billed.
The physician only ordered a Urinalysis Screen, so an automated microscopy should not have been included and will not be reimbursed by Medicare.
Resources:
CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 16 - Laboratory Services