Coming in 2006! Beginning January 1, 2006, Medicare prescription drug coverage will be available to people with Medicare. Health care professionals can find information about this new coverage at www.cms.hhs.gov/medlearn/drugcoverage.asp, on the CMS website.

Announcing the new CMS web page dedicated to providing all the latest NPI news for Fee-For-Service (FFS) Medicare providers! Visit http://www.cms.hhs.gov/NationalProvIdentStand/ on the web! While this page is dedicated to the Medicare FFS community, it contains helpful information and links that may benefit all health care providers.

Reminder--Health care providers are required by law to apply for a National Provider Identifier (NPI). To apply online, visit: https://nppes.cms.hhs.gov,

Related Change Request (CR) #: 3835

Related CR Release Date: October 28, 2005

Related CR Transmittal #: 734

Effective Date: October 1, 2004

Implementation Date: April 3, 2006

All hospitals billing for non-patient lab specimens, but particularly Maryland Hospitals billing Medicare fiscal intermediaries (FIs) for laboratory services for their outpatients and for non-patients and critical access hospitals (CAHs) billing FIs for laboratory services for their outpatients and for non-patients.

Affected providers must stop using Type of Bill (TOB) 14x when billing for referred diagnostic tests and reserve the use of TOB 14x for non-patient laboratory specimens.

Be aware of the redefinition of TOB 14x for use in billing tests for non-patient laboratory specimens, which Medicare pays for based on the Clinical Diagnostic Laboratory Fee Schedule. When the lab tests are provided in Maryland, services to a hospitals own outpatients are paid under the state cost containment system. When tests are performed on non-patient specimens, they are categorized as non-patient specimen only lab tests. The same distinction applies to CAHs. When the lab tests are performed for the CAHs own outpatients there are paid based on cost. When they are performed on non-patient specimens the tests are paid based on the lab fee schedule.

Use the redefined TOB 14x for non-patient laboratory specimens as discussed in this article.

While 85x TOB is still used for lab tests, it is only valid if the patient is an outpatient of the CAH and physically present at the time the specimen is collected. A CAH cannot seek reasonable cost reimbursement for tests provided to individuals in locations such as a rural health clinic, a provider-based home health agency, the individuals home, or a physicians office. Individuals in these locations are nonpatients of the CAH and their lab tests are categorized as non-patient specimen only lab tests. For these non-patients, use TOB 14x and Medicares payment will be made under the lab fee schedule.

In the early 1990s, the definition of 14x was changed to be all referred diagnostic services and, subsequently, there was no adequate method to distinguish the non-patient specimens. The changed definition of TOB 14x was confusing to both providers and FIs. Due to this lack of clarity, and the need to pay both Maryland hospitals and CAHs on the lab fee schedule when only the specimen is received and the need to distinguish for certain pathology tests, the Centers for Medicare & Medicaid Services (CMS) is introducing a revised definition of TOB 14x for non-patient specimens. These specimens will be paid on the clinical diagnostic lab fee schedule, as opposed to on the basis of reasonable cost or percent of charges.

The implementation date for this instruction is April 3, 2006.

The official instruction issued to your FI regarding this change may be found by going to http://www.cms.hhs.gov/Transmittals/ on the CMS web site. From that web page, look for CR3835 in the CR NUM column on the right, and click on the file for the desired CR.

If you have any questions regarding this bulletin, please contact the appropriate Customer Contact Center at:

Maryland Providers: 1-866-488-0545
Pennsylvania Providers: 1-800-560-6170