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Billing Information

Shiel Medical Laboratory offers several different billing arrangements, based upon information provided to us by the physician/client on the test request form, and in accordance with all applicable rules and regulations governing the billing of laboratory tests.  Progressive/reflex test that are ordered and performed will be billed separately.

INDUSTRIAL MONTHLY BILL CLIENT

Charges accumulate daily as testing is completed and invoices are forwarded at the beginning of each month detailing charges for the previous month’s services.  Payment is due upon receipt.  Any discrepancies must be reported in writing.  Adjustments will appear on subsequent invoices.  Payments for all non-disputed balances remain due upon receipt.

As a service to our clients, we have t\provided the American Medical Association’s (AMA) Current Procedural Terminology (CPT) codes for tests listed on our Test Menu.  It is the responsibility of the client to research and verify the accuracy of CPT codes they use for billing purposes.  CPT guidelines are published by the AMA and are also available from many insurance carriers.

CPT codes provided in our Test Dictionary are provided as a guide and can change at any time.  The CPT codes are based upon AMA guidlelines and should be used for informational purposes only.  CPT coding is the sole responsibility of the client.  Please direct any inquiries regarding CPT coding to the payor being billed.

INSURANCE BILL

Insurance claims will be filed on behalf of any patient who is enrolled with a carrier on their date of service, provided their Insurance carrier will accept and process claims from Shiel Medical Laboratory.  Shiel Medical Laboratory participates with a variety of traditional insurance plans and managed care organization (HMOs and PPOs).  Please contact your Shiel Sales Representative for an up-to-date insurance list of those plans with whom we participate or view the Insurance Tab on our website.  When appropriate, we will bill a patient directly upon receipt of a claim rejection.

Insurance plans are billed at the same prices billed to patients.  Insurance providers require diagnosis information on the test request form in order to process a claim for laboratory services.  Only the physician/client may supply this information.  Please provide diagnosis in the ICD-9 (International Classification of Diseases) format.  ICD-9 manuals are available from various publishers.

Diagnostic information must be provided in ICD-9 format when insurance billing is requested.

PATIENT BILL

If requested, or as required by law, Shiel will bill patients directly, according to the Patient Fee Schedule.  These fees may vary from those charged to third party providers.  Panels and/or profiles that do not conform to specific CPT codes will be billed as the individual test components.
The patient’s full name and address must appear on the test request form.  Please note that many patients may subsequently request insurance billing for those plans with which Shiel Medical Laboratory participates.  In those cases, diagnosis information will be required in order to file a claim with the provider and we will contact your office for this information if it has not been provided.  Shiel is unable to accept diagnosis information from a patient.  If a patient is enrolled in a health plan with with whom we participate, please provide the patient’s insurance information on the date of service, the applicable diagnosis information, and request Shiel bill the carrier on behalf of the patient.

MEDICARE

Under the Medicare statute, a laboratory must bill Medicare directly for clinical laboratory services.  Physicians may not bill the Medicare program for laboratory tests they do not perform.

Clinical diagnostic laboratory tests are reimbursed on the basis of the Clinical Laboratory Fee Schedule (CLFS).  The following procedures are exempt from fee schedule reimbursement.

  • Anatomic Pathology Consultations
  • Clinical Pathology Consultation
  • Blood Bank Services
  • Blood Smears with written interpretations
  • Certain other Cytopathology services
  • Bone Marrow Smears and Biopsies
  • Surgical Pathology Services

Medicare reimburses for these procedures at 80% of the approved amount and requires that the patient be billed for the remaining 20% copayment and any applicable deductible.

MEDICAL NECESSITY

When ordering tests for which Medicare reimbursement will be sought, physicians or authorized individuals, should only order tests that are medically necessary for the diagnosis and treatment of a patient, rather than for screening purposes.  Only those tests defined in the Patient Affordable Care and Protection Act, meeting certain guidelines, may be ordered as screening tests.  The Office of Inspector General takes the position that a physician who orders medically unnecessary testing many be subject to civil penalties.

The Centers for Medicare and Medicaid Services (CMS) has implemented uniform National Coverage and Administrative Policies for clinical laboratory services to ensure the medical necessity of certain services rendered to Medicare beneficiaries.  In addition to the National Coverage Policies subject to National Coverage Determination (NCD), CMS allows Medicare Carriers to develop their own local coverage policies referred to as LCD (Limited Coverage Determination).  The list of LCD tests vary among Medicare carriers.

Many of the procedures subject to NCD and LCD are for clinical laboratory testing.  Once an NCD or LCD is in place for a test, the carrier requires medical necessity documentation in order to determine coverage.  A carrier will deny coverage for a national or limited coverage test when it is submitted without specific diagnosis information which supports the medical necessity for the testing.  Documentation of medical necessity for laboratory tests is reported to the carrier with a code from the International Classification of Diseases (ICD-9).  Please contact your Shiel Medical Laboratory Sales Representative for a list of NCD/LCD tests with appropriate ICD-9 codes.

Whenever you order a test that is subject to NCD or LCD, an ICD-9 code is required on the test request form.  The ICD-9 code  should indicate the medical necessity that you, in your judgment, believe is appropriate for the test.  Please provide the ICD-9 code(s) which most accurately describe the patient’s condition.  Do not choose a code merely to secure claim payment.  ICD-9 codes must be provided in valid format, including the 4th and 5th digit specificity, when required.  The ICD-9 code that you provide must appear in the patient’s medical record in order to support the medical necessity of the testing in the event of a post-payment review.

Whenever possible, tests that are subject to NCD or LCD guidelines, as determined by Shiel Medical Laboratory’s Medicare carrier, are printed in red on our test request form, or highlighted with a prompt on our LabCare Plus computer system.  The Medicare carrier may adopt additional LCDs for other tests at any time.

Copies of our Medicare carrier’s LCDs are available.  Please contact your Shiel Laboratory Sales Representative.  We will advise you of NCD and LCD updates when issued.

ADVANCE BENEFICIARY INFORMATION

In the event that a test is determined by Shiel Medical Laboratory’s Medicare carrier to be medically unnecessary, the laboratory may only bill the patient if an Advance Beneficiary Notice (ABN) has been completed and signed by the patient before  the specimen is collected.  The ABN appears on the back of the first page of any test request form, which includes a list of tests that are subject to NCS or LCDS.

Medicare’s medical necessity requirements for coverage many not always be consistent with the reasons why you believe a test is appropriate for a patient.  Nevertheless, when you have reason to believe a test may be considered medically unnecessary by Medicare, the patient should be asked to sign a completed ABN.  A new, original ABN must be completed and signed each time such conditions exist.  An ABN signature may not be requested solely on the basis that a test being ordered is subject to NCDs or LCDs.

The ABN ensures that the patient understands that he/she will be responsible for any services marked on the form that Medicare does not cover for one of the following reasons:

  • The test is subject to an NCD or LCD and the diagnosis for which the test is ordered is not considered to be indicative of medical necessity by Medicare.
  • The test is ordered more frequently than Medicare considers medically necessary.
  • The test is for research or investigation use only and is not approved by the Food and Drug Administration.

All of the information on the ABN must be completed.  The test(s) you believe will be considered by Medicare to be medically unnecessary must be clearly marked.  If you must write a test name on the ABN, please write the test name as it appears on the test request form.   Do not use synonyms or abbreviations.

Please make sure the patient reads, understand, and signs the ABN prior to specimen collection.  If the patient is unable to sign, the form should be marked with an “X” and the patient’s guardian, guarantor, or other responsible party should sign the form.

Separate ABN form are available for those clients who order tests electronically.  A bar code label for the accession related to the separate ABN should be placed in the upper right hand corner of the ABN.  These completed ABNS should be placed in a separate envelope and sent directly to the Billing Department via your daily courier service.  Please contact your Shiel Medical Laboratory Representative to obtain these forms.