Compliance Notice to Physicians

We recognize and are committed to doing business in accordance with the highest medical, ethical, legal, and regulatory standards. To help clinical laboratories comply with federal laws and regulations, the Office of the Inspector General (OIG) of the Department of Health and Human Services issued its August 1998 Compliance Program Guidance for Clinical Laboratories.

 

These guidelines include information on how laboratories and their clients can avoid submitting false claims to government and non-government insurance plans. Using the Compliance Program Guidance, we created a voluntary compliance program, relevant portions of which are highlighted below.

 

 

To help guide you in the appropriate choice of tests for a specific clinical or medical condition, we offer clinical consultation with our medical and scientific directors, directors and affiliated pathologists, as required under the Clinical Laboratory Improvement Amendments (CLIA) (42CFR 493.1453).

 

You can reach our medical and scientific directors and affiliated pathologists by calling 505-938-8888 or toll-free 800-245-3296. For a list of our clinical consultants, click here.

 

 

Medicare reimburses only for tests that are medically necessary for the diagnosis and treatment of illness or injury to your patient. To be covered by Medicare, laboratory tests must be ordered by a healthcare provider or other authorized individual and must be intended for diagnostic rather than screening or prevention purposes, with certain statutory exceptions.

 

The Office of the Inspector General (OIG) takes the position that physicians who knowingly order medically unnecessary tests for which Medicare reimbursement is claimed may be subject to sanctions or penalties under civil, criminal, or administrative law.

 

Healthcare providers must include the diagnosis on the requisition in order for TriCore to submit the claim to Medicare. The lists of tests for which medical necessity is limited to certain covered diagnoses is subject to change on a regular basis. A complimentary copy of the Medicare coverage lists is available from TriCore [by calling the compliance officer?].

 

The most up-to-date National Coverage Determinations (NCDs) are available at www.cms.hhs.gov/CoverageGenInfo.

 

Updated Local Coverage Determinations (LCDs) can be found at www.trailblazerhealth.com.

 

A “false claim” is defined as a misrepresentation to the federal government to obtain money to which one is not entitled. A false claim includes presentation of a claim for a service that the provider knows is not “reasonable and necessary” according to Medicare’s definition of medical necessity. False claims also include claims that provide an incorrect diagnosis code for a specific service to obtain reimbursement for that service. Healthcare providers must make every effort to include all appropriate diagnosis codes for each patient encounter during which laboratory orders are generated.

 

The current Medicare laboratory fee schedule is available on request from TriCore’s compliance officer. Please note that Medicaid reimbursement will be equal to or less than the Medicare reimbursement.

 

For more detailed information, contact TriCore’s compliance officer at 505-938-8330 or toll-free at 800-245-3296 Ext. 8330, or by email at compliance@tricore.org.

 

Providers must document medical necessity when ordering any of the panels on the list below for their Medicare patients by providing all narrative diagnoses or ICD-9 codes appropriate to the patient visit.

 

 

Sodium	X	X	X	X			X
Potassium	X	X	X	X			X
Chloride	X	X	X	X			X
Carbon Dioxide (Bicarbonate)	X	X	X	X			X
Anion Gap (AGAP) (calculation)	X NOT BILLED	X NOT BILLED	X NOT BILLED	X NOT BILLED			X NOT BILLED
Glucose	X	X		X			X
Urea Nitrogen (BUN)	X	X		X			X
Creatinine	X	X		X			X
Calcium	X	X		X			X
Albumin				X	X		X
AST (SGOT)				X	X
ALT (SGPT)				X	X
Bilirubin				X TOTAL	X TOTAL & DIRECT
Phosphatase, Alkaline				X	X
Protein, Total				X	X
Globulin (calc)				X NOT BILLED
Phosphorus							X
Triglyceride						X
Cholesterol						X
HDL						X
LDL (calc)						X NOT BILLED
Hepatitis A Antibody, IgM								X
Hepatitis B Core Antibody, IgM								X
Hepatitis B Surface Antigen								X
Hepatitis C Antibody								X