2018 Medicare Laboratory Fee Schedule (MLFS)

Which Medicare MAC has the best laboratory reimbursement?

Apache Health often gets questions about which locality or which Medicare region (MAC) has the best reimbursement rates.  Even a number of years ago some labs sought to locate in favorable reimbursement locations in order to maximize their reimbursement.  None of that matters any longer. 

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Do Outsourced Medical Billing Companies Really Deliver?

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Medical billing, like many industries, has had its share of debate over the merits of outsourcing the work.

Some providers have experienced sub-par medical billing companies that only go after the low hanging fruit, while others have found that outsourcing has saved their practice and they will never go in house again.

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Palmetto GBA awarded MAC J

On September 7, 2017, CMS awarded Palmetto GBA a new contract to administer the claims processing for Medicare for Part A and Part B for MAC Jurisdiction J.  This is a one year guaranteed contract with up to four additional one year extensions.

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Do Laboratory Billing Services Really Deliver?

Medical billing, like many industries, has had its share of debate over the merits of outsourcing the work. Some laboratories have experienced sub-par medical billing companies that only go after the low hanging fruit, while others have found that outsourcing has saved their laboratory and they will never go in-house again.

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2017 Toxicology Laboratory Billing

It seems that toxicology billing is not going to get any simpler.  Already this year, the CMS has reversed themselves for the second year in a row. The qualitative codes G0477, G0478, G0479 were deleted, after being introduced in 2016.  Those codes were replaced with 80305-80307.  These new codes were essentially the same as the old ones, other than the addition of a few more methods of instrumented chemistry analysis. CMS also eliminated the separate validity testing codes 84311, 83986, 82570, the functions of which were rolled up under other existing codes.

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2017 Pain Management Billing Mid-year MACRA Update

CMS (Centers for Medicare and Medicaid, aka Medicare) has changed its post-operative visit reporting requirements for straight Medicare patients.  It is effective July 1, 2017.  At this time it is limited to a subset of providers.

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Results Are In – Toxicology Billing is a Mess

As drug abuse reaches crisis levels for many communities across the country, accurate and reliable toxicology testing has grown more critical in the public health arena.  With lives in the balance, newer and better testing technologies will be required to meet this challenge, and that will, of course, have a downstream impact on laboratory billing practices.

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The Top Five Myths of Medical Billing

Common performance claims of medical billing companies, and why you should question them.

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Apache Quoted in Huffington Post

Apache Health was asked to comment for Huffington Post about coding compliance in ER visits and we ended up being quoted in an article about how to beat a hospital bill. While our intent was not to show people how to evade paying for services they actually received, it does serve as a warning to practices to ensure coding compliance to avoid not only legal issues, but to ensure they actually get paid for the health care they provide.

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Non-Partisan Why It’s Good the Senate Healthcare Bill is Dead

As with prior articles, this is not a partisan piece and does not look at or address political ideology.  Our goal is to evaluate these on the basis of financial impact to the country and healthcare providers since these are our clients.

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2017 Unwelcome Surprise Medical Bill Laws - aka Balance Billing

There has been a great deal of coverage in the press about unwelcome surprise medical bills, and Apache Health provides this article with the intent to help providers with information on the laws and regulations surrounding balance billing nationally and in their state.  This is intended for facility-based physician groups for anesthesia billing, radiology billing, hospitalist billing, and pathology billing who often balance bill a patient in full when they are out of network.

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Finding a Top Neurosurgery Billing Service

Finding a top medical billing service can be extremely difficult.  Some practices go through many billing companies before finding one that meets their needs and delivers excellent financial performance.

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How the 2017 Senate Healthcare Bill Impacts Providers Financially

The United States Senate this week proposed a bill that would constitute a major overhaul of the US healthcare system.  It has some potential major implications for medical billing.

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Patient Balance Billing Lawsuits

Billing out-of-network can be extremely complex, especially with respect to patient balance billing.  Due to being the leading medical billing company when it comes to out-of-network billing, Apache Health often gets questions from our clients and prospective clients on whether they can balance bill patients in full or waive patient balances.

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2017 Orthopedic Billing – Foot and Ankle

As the leading orthopedic billing company, Apache Health determines what if any changes in orthopedic billing will be enacted for the coming year every December.  Apache then writes up the changes and distributes this to our clients and educates them on the forthcoming changes, as well as any implications on their reimbursement.

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Any Willing Provider Statutes

The Provider-Payer Battle

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Pain Management Billing LCD’s, NCD's, and Payer Policies

Apache Health as a leading pain management and neurosurgery billing company often gets questions about specific billing issues from our clients and prospective clients.  This article looks at some of the issues faced in pain management billing with respect to Medicare Local Coverage Determinations (LCD’s), National Coverage Determinations (NCD’s), and other commercial payer policies.

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California Medical Billing - Balance Billing Pt 2

Apache Medical Billing frequently gets questions about California medical billing rules and regulations, and in particular about the potential impact on facility based physician groups like for anesthesiologist billing, radiologist billing, and hospitalist billing of the new Balance Billing Law California AB 72.  In part 2 of the California medical billing rules and regulations regarding patient balance billing, we discuss specifically California AB 72.

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California Medical Billing - Balance Billing

Apache Health receives frequent inquiries about California medical billing and whether it is legal to balance bill in full or contrarily to waive patient balances.  As noted in greater detail in some prior articles we have written, facility-based physician groups like for anesthesia billing, radiology billing, hospitalist billing, and ER billing often seek to balance bill a patient in full when they are out of network, however facilities like ASC billing, laboratory billing, and imaging center billing often seek to waive the patient balances in whole or in part when billing out of network.  Following is some information specific to California rules and regulations regarding patient balance billing.

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Waiving Patient Balances – Part 2

We frequently get medical billing questions from out of network providers (non-contracted) especially for referral-based facilities like imaging center billing, laboratory billing, and ASC  billing is whether they can waive patient balances.  Following is the second part to the article about the rules and regulations surrounding waiving patient balances that may help your practice.

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Waiving Patient Balances – Part 1

One of the most common medical billing questions we get from out of network providers (non-contracted) especially for referral-based facilities like imaging center billing, laboratory billing, and ASC billing is whether they can waive patient balances.  Following is some information that may help your practice.

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Cash Pay Discounts in Medical Billing

Apache Health frequently gets medical billing questions from our clients about “cash pay discounts”, whether they are legal, can they provide them, and how much of a discount is legally allowed?  This is part of our ongoing series about the rules and regulations surrounding medical billing.

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Medical Billing - Treating Patients As If "In Network"

The last medical billing article in this series discussed the potential benefits of medical billing out of network with a high fee schedule.  We concluded that billing a higher fee schedule out of network generated more revenue per encounter for physicians and other providers with the limiting factor being high patient balances and balance billing.  In this article we will discuss one of the ways in which a provider can lessen the impact on patients of billing a high fee schedule OoN.

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Out of Network Medical Billing

In past medical billing articles have discussed the mechanics of patient balance billing.  We have also briefly discussed why providers may want to bill out of network because in theory should get higher reimbursement.  In this article we will discuss medical billing out of network, it's benefits, fee schedule optimization, and implications for patient balance billing.

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Patient Balance Billing

Myth and misinformation is rampant in this industry.  Ask a dozen different medical billing companies whether or not it is legal to balance bill patients and you will get a dozen different answers, most of which will be wrong and all of which will be supported by the fact that they present themselves as “medical billing experts”.

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California Medical Billing Problems

Medical billing in California is a world unto itself. For anyone who has handled medical billing here, you are well aware of the fact that thanks to an ever changing and more complex coding system in the state, taking care of billing both your patients and their insurance companies has become very time consuming.

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Molecular Diagnostics Coding 2015

Molecular diagnostics laboratory billing have become increasingly complex over time.  This trend continues with a whole series of additional codes and some revisions for 2015.  Molecular Pathology, MoPath, Molecular Diagnostics, MolDx are the names applied to a series of laboratory genomic / genetic tests.

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2015 Toxicology Coding Crosswalk

2014-2015 Toxicology Coding Crosswalk    
Nature of Testing/Item Tested 2015 CMS CPT 2015 AMA
CPT
2014
CPT
PRESUMPTIVE DRUG CLASS SCREENING      
    80300  
SCRN-1 -Drug screen, any number of drug classes from Drug Class List A; Direct optical observation, including instrumented-assisted (dipsticks, cups, cards, cartriges), non-TLC devices or procedures per date of service      
    80301  
SCRN - 2 - Drug screen, any number of drug classes from Drug Class List A; single drug class method, by instrumented test systems (eg, discrete multichannel chemistry analyzers utilizing immunoassay or enzyme assay), per date of service      
    80302  
SCRN - 3 - Drug screen, presumptive, single drug class from Drug Class List B, by immunoassay (eg, ELISA) or non-TLC chromatography without mass spectrometry (eg, GC, HPLC), each procedure      
    80303  
SCRN - 4 - Drug screen, any number of drug classes, presumptive, single or multiple drug class method; thin layer chromatography procedure(s) (TLC) (eg, acid, neutral, alkaloid plate), per date of service      
    80304  
SCRN - 5 - Drug screen, any number of drug classes, presumptive, single or multiple drug class method; not otherwise specified presumptive procedure (eg, TOF, MALDI, LDTD, DESI, DART), each procedure      
CMS IS USING "DRUG SCREEN" EACH PROCEDURE FOR G0431, G0434 G0431   80101
       
       
Acetaminophen G6039 See 80329-80331 82003
Alcohols G6040 80320 82055
Alcohol biomarkers- 1 or 2   80321  
Alcohol biomarkers - 3 +   80322  
Alkaloids; urine; Quantitative G6041 80323 82101
Alkaloids not otherwise specified   80323  
Amitryline G6030 See antidepressants, Tricyclic and other cyclicals; 80335-80337 80152
Amphetamines - 1 to 2 analytes G6042 80324 82145
Amphetamines; 3 or 4   80325  
Amphetamines - 5 or more analytes   80326  
Amobarbital   80345  
Anabolic Steroids - 1 or 2   80327  
Anabolic Steroids - 3 or more   80328  
Analgesics - non-opioids - 1 or 2 drugs   80329  
Analgesics - non-opioids - 3-5 drugs   80330  
Analgesics - non-opioids - 6 or more drugs   80331  
Antidepressants, serotonergic class; 1 or 2 drugs   80332  
Antidepressants, serotonergic class; 3-5   80333  
Antidepressants, serotonergic class; 6 or more   80334  
Antidepressants, tricyclic and other cyclicals; 1 or 2 drugs   80335  
Antidepressants, tricyclic and other cyclicals; 3-5   80336  
Antidepressants, tricyclic and other cyclicals; 6 or more   80337  
Antidepressants, not otherwise specified   80338  
Antiepileptics, not otherwise specified; 1-3 drugs   80339  
Antiepileptics, not otherwise specified; 4-6   80340  
Antiepileptics, not otherwise specified; 7 or more   80341  
Antipsychotics, not otherwise specified; 1-3 drugs   80342  
Antipsychotics, not otherwise specified; 4-6   80343  
Antipsychotics, not otherwise specified; 7 or more   80344  
Barbiturates G6043 80345 82205
Barbiturates, qualitative   80345  
Benzodiazepines; 1-12 G6031 80346 80154
Benzodiazepines; 13 or more G6031 80347  
Buprenorphine and metabolites   80348  
Cannabinoids, natural   80349  
Cannabinoids, synthetic; 1-3   80350  
Cannabinoids, synthetic; 4-6   80351  
Cannabinoids, synthetic; 7 or more   80352  
Carbon tetrachloride 82441 82441 84600
Cocaine or metabolite G6044 80353 82520
Cocaine, qualitative   80353  
Codeine, qualitative   See Opiates; 80361  
Desipramine G6032 See Antidepressants, Tricylic and other cyclicals; 80335-80337 80160
Dichloroethane 82441 82441 84600
Dichloromethane 82441 82441 84600
Dihydrocodeinone G6045 See 80361 82646
       
Dihydromorphinone G6046 See 80361 82649
       
Doxepin G6034 Antidepressants, Tricylic and other cyclicals; 80335-80337 80166
DRUG CONFIRMATION, EACH PROCEDURE     80102
Epiadrosterone G6049 See Anabolic Steroids; 80327-80328 82666
Ethchlorvynol G6050 See Alcohols; 80320 82690
Fentanyl and metabolite   80354  
Flurazepam G6051 See Benzodiazepines; 80346-80347 82742
       
Gabapentin (non-blood)   80355  
Heroin Metabolite (6-Acetylmorphine)   80356  
       
Imipramine G6036 See antidepressants, Tricyclic and other cyclicals; 80335-80337 80174
Isopropyl Alcohol   See Alcohols; 80320 84600
Ketamine and norketamine   80357  
Marihuana   See cannabinoids, natural 80349  
Meprobamate G6052 See Skeletal muscle relaxants; 80369, 80370 83805
Meprobamate QUALITATIVE   See Skeletal muscle relaxants; 80369, 80370  
Methanol   See Alcohols; 80320 84600
Methadone and metabolite G6043 80358 83840
Methylenedioxyamphetamines (MDA, MDEA, MDMA)   80359  
Methylphenidate   80360  
Methsuximide G6054 See Antipipleptics, NOS; 80339-80341 83858
Nicotine G6055 See Alkaloids, nos; 80323 83887
Nortriptyline G6037 See Antidepressants, Tricyclic and other cyclicals; 80335-80337 80182
Opiates, drug AND metabolites; Each procedure, including nalorphine) G6056 See Opiates; 80361 83925
Opiates, 1 or more G6056 80361  
Opioids and opiate analogs; 1 or 2 G6056 80362  
Opioids and opiate analogs; 3 or 4 G6056 80363  
Opioids and opiate analogs; 5 or more G6056 80364  
Oxycodone   80365  
Phencyclidine   83992  
Phenothiazine G6057 See Antipsychotics, NOS; 80342-80344 84022
Phenothiazine, qualitative   See Antipsychotics, NOS; 80342-80344  
Pregabalin   80366  
Propoxyphene and metabolite   80367  
Salicilates G6038 See Analgesics, non-opioid; 80329-80331 80196
Sedative hypnotics (non-benzodiazepines)   80368  
Skeletal muscle relaxants; 1 or 2   80369  
Skeletal muscle relaxants; 3 or more   80370  
Stimulants, synthetic   80371  
Tapentadol and metabolite   80372  
Tramadol and metabolite   80373  
Stereoisomer (enantiomer) analysis, single drug class   80374  
       
CATCHALL      
Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 1 to 3   80375  
Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 4 to 6   80376  
Drug(s) or substance(s), definitive, qualitative or quantitative, not otherwise specified; 7 or more   80377  
       
THERAPEUTIC      
Digoxin; free 80163 80163  
Valproic acid (dipropylacetic acid); free 80164 80164  
       
UNCLASSIFIED TO DATE OR WILL FALL INTO CATCHALL      
11 Cotinine   See Alkaloids, NOS, 80323  
12 Desomorphine (Krokodil)   See Opioids and opiate analogs; 80362-80364  
13 Dextromethorphan (DXM)   See Opioids and opiate analogs; 80362-80364  
20 Methamphetamine   See Amphetamines; 80324-80326  
22 Mitragynine   See Alkaloids, NOS, 80323  
27 Phencyclidine (PCP)   83992  
32 Synthetic Cathinones (Bath Salts)   See stimulants, synthetic; 80371  

 

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