Apurva Posted Wed 05th of February, 2020 22:15:05 PM
For billing GIPP testing in EVICORE guidelines we have the criteria mentioned - "If the laboratory’s testing platform consists solely of a multiplexed panel of 12 or more targets, yet only a subset of the organisms are considered medically necessary based on the above criteria, the lab may request reimbursement for that subset of organisms using a procedure code that does not represent all organisms included on the panel " . Need help on understanding the concept of requesting reimbursment
SuperCoder Answered Thu 06th of February, 2020 05:54:14 AM
Thank you for the Question!
As per CMS, Contractor/payer provide limited coverage for Gastrointestinal Pathogen (GIP) molecular assays identified by multiplex nucleic acid amplification tests (NAATs) and will limit GIP coverage in immune competent beneficiaries up to 5 bacterial targets which represent the top 90-95% of foodborne infections.
When there is a clinical concern for any specific organism. If the contractor covers up to 11 targets then that specific organism is one of the organisms tested for.
Testing for 12 or more organisms will only be covered in critically ill or immunosuppressed patients. In immune-competent individuals, most people with Cryptosporidium, a parasitic disease, will recover without treatment. The pathogens in some of the GIP panels are determined by the manufacturers that make them, and do not represent specific pathogens that cause a common age-based syndrome, or represent organisms that commonly are found in a specific sample type, patient population or reflect community-acquired foodborne infections. Because of the unique clinical circumstances of immune-compromised patients, ICU patients, and HIV positive patients with diarrhea, GIP testing for bacteria, virus and parasite testing may be indicated, and thus a Medicare benefit.
Some laboratories elect to use GIP panel tests but report only the specific tests ordered by the physician. In other words, and the laboratory “blinds” unnecessary test results or utilize disclaimers in their reporting and bill only for the medically necessary test results. Other laboratories report results of all tests in the panel which adds unnecessary cost to the healthcare system when reimbursement is directly related to the number of organisms in the panel.
Hope that Helps!
Apurva Posted Thu 06th of February, 2020 05:59:47 AM
can any link or articles be shared with respect to BCBX texas policy /Medicarepolicy
SuperCoder Answered Fri 07th of February, 2020 04:50:24 AM