Blog Details

Medicare Administrative Contractors (MACs) Novitas Solutions and First Coast Service Options (FCSO) have introduced new documentation requirements with new code sets for submitting the claims for pathology and laboratory services.

MACS are implementing a new requirement for pathology and laboratory claims submissions starting September 19, 2024.

Providers must now submit medical records with initial claims for specific pathology and laboratory (path/lab) codes. Claims that do not include the necessary documentation will be rejected.

New Lab Billing Process

Here’s a breakdown for laboratory/pathology billing process according to newly introduced documentation requirements and procedure codes.

New Path/Lab Codes

The new policy requires documentation for initial claims associated with specific path/lab codes. The updated code set includes 39 codes, primarily for proprietary laboratory analysis (PLA) tests.

Many of these codes were introduced in the July 1 CPT® update. Notably, the list includes CPT® 0020M, which pertains to a complex multianalyte assay used in oncology to analyze DNA methylation loci in tumor tissue.

The 39 procedure codes for pathology and laboratory billing with details are listed below:

0020M, 0421U, 0422U, 0425U, 0426U, 0428U, 0429U, 0434U-0439U, 0441U-0443U, 0445U, 0448U-0456U, 0459U-0461U, 0464U-0469U, 0471U, 0472U, 0474U, 0475U

Required Documentation

For claims involving the specified codes, the following documentation must be included:

• Orders and Test Results: Proof of the test ordered and the resulting findings.
• History and Physical Examination: Documentation detailing the patient’s medical history and physical examination relevant to the test.
• Progress or Office Notes: Notes from progress or office visits that support the necessity of the test.
• Additional Supportive Documentation: Any other relevant medical records that justify the service provided.

Key Takeaways for Providers

• Effective September 19, 2024, claims for specified path/lab codes must include medical records. Ensure that all initial claims are accompanied by the required documentation to avoid rejections.
• The list of path/lab codes requiring documentation can change. Providers should regularly review the list provided by Novitas and FCSO, especially for updates.
• Include all necessary documents such as test orders, results, history and physical examinations, progress notes, and any additional relevant records.
• Understand which MAC serves your region and ensure compliance with their specific requirements. Different regions have different MACs (Novitas or FCSO), so be familiar with the rules applicable to your area.
• Claims lacking the required documentation will be rejected, potentially delaying reimbursement and affecting practice revenue. Ensure all documentation is complete and accurate before submission.

Conclusion

The new billing requirements by Novitas and FCSO emphasize the importance of thorough documentation for specific pathology and laboratory codes. Providers need to adapt their processes to ensure that all necessary medical records are submitted with initial claims to avoid rejections and delays. By staying informed about the required codes and maintaining detailed documentation, providers can ensure smoother claim processing and uphold compliance with the new billing procedures.