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* Is our compliance checker wrong?
* Can we leave answering machine messages under HIPAA?
* Pay-per-view article: Hot trends in antitrust enforcement: PHOs and Mergers

Compliance Monitor, May 19, 2003

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Is our compliance checker wrong?

Q: Our laboratory is not billing for antibiotic sensitivity susceptibility studies (CPT 87184 and CPT 87186) for any non-urine susceptibility. For a non-urine culture, our compliance checker prompts us to obtain an advance beneficiary notice (ABN). The checker claims that we must abide by the National Coverage Determinations (NCD), and we agree. But is our compliance checker interpreting this NCD inappropriately, or is this an omission by the Centers for Medicare and Medicaid Services (CMS)? If so, what is it? Any help resolving this significant issue would be most appreciated.

A: You should be able to bill for susceptibility testing on non-urine cultures if the reason for the testing meets the medical necessity requirements for that particular test. You should refer to your Local Medical Review Policies for the diagnosis that meets medical necessity for certain lab testing.

If your compliance checker is defaulted to tell you that an advance beneficiary notice (ABN) is necessary, based on a "test alone," then that doesn't completely meet ABN requirements in most instances. Most routine lab tests, such as an annual screening test, might require ABN's, but it depends on the "reason why the patient went to the physician." The patient might have "signs and symptoms" that would meet medical necessity and allow reimbursement for the tests ordered.

With National Coverage Determinations (NCD), the Centers for Medicare and Medicaid Services (CMS) tries to specify a uniform set of diagnoses that demonstrate the medical necessity of certain lab tests. See 66 Federal Register 13083 and CMS Program Memorandum AB-02-87 (June 26, 2002) for more information on this topic.

A urine culture is one of those selective lab tests. For a carrier to reimburse you for a urine culture, you must assign an acceptable diagnosis to meet medical necessity rules.

The purpose of an ABN is to provide patients with a notice that CMS may not cover the test ordered by their referring physician, and so the patient may be financially responsible for payment. Treating physicians must determine whether the diagnosis they attach to the laboratory tests ordered meets medical necessity requirements. This will help them determine whether an ABN is appropriate. When a test is not listed on the NCD, that does not mean an ABN is required. You must determine this on a case-by-case basis.

This question was answered by Rick Oliver, JD, CHCO, CPC, MT (ASCP), director of compliance at AmeriPath, Inc.

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Pay-Per-View article: Hot trends in antitrust enforcement: PHOs and Mergers

Second in a two-part series on antitrust laws

Last month, we explored the statutory framework of the federal antitrust laws, particularly Sections 1 and 2 of the Sherman Antitrust Act and Section 7 of the Clayton Antitrust Act. Section 1 governs contracts, combinations, and conspiracies to restrain trade, Section 2 prohibits organizations from forming monopolies, and Section 7 governs mergers...

Go to "Validate compliance program effectiveness through auditing" for the rest of this article. The cost is $10. Subscribers to the online version of Strategies for Health Care Compliance have free access to this article. Subscribers to the print edition can find it in their May issues.

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Can we leave answering machine messages under HIPAA?

Under the Health Insurance Portability and Accountability Act (HIPAA), can physicians or their nurses leave a message on a patient's answering machine in relation to dosage change for medication? If not, are there some alternatives we can consider?

A: Leaving messages on a patient's answering machine is acceptable, but there are several issues to consider for each patient. As a general policy, your office should use the minimum amount of information necessary to accomplish the task.

If you want to give specific instructions or results to the patient, such as a medication dosage change or lab results, it might be better to have the patient call you back for details. However, you could ask for the patient's permission to leave messages if your office has to call the patient quite often.

Your Notice of Privacy Practices should also mention that your office may "leave messages for the patient concerning their health care." Patients may request no messages, and they may request an alternate communication method. Be prepared to address this, should it come up.

This question was answered by Marion Neal, President of HIPAASimple.com.

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