Dayton General Hospital Laboratory
Monday through Friday 7:00 am - 6:00 pm. Phone (509)382-3201
Regulatory Information
Laboratories that accept Medicare assignment are not allowed to bill Medicare beneficiaries for covered tests. However, there are many situations where authorized healthcare providers order tests that are not covered by Medicare. These tests can be billed to the Medicare beneficiary if the laboratory executes a valid waiver (ABN) by informing the beneficiary in advance of the service that they will be responsible for payment for the tests if Medicare should deny payment. The situations where ABNs are appropriate include the following:
1. Tests that are ordered for a diagnosis or condition that in Medicare’s opinion are not medically necessary, or for which a diagnosis is not available at the time of service.
2. “Screening “ tests that are performed as a part of a routine examination where the patient displays no evidence of disease;
3. Tests that are performed more frequently than recommended by Medicare; or
4. Tests that are considered experimental or investigational because they have not been approved by the Food and Drug Administration.
It is the policy of DGH to request an ABN from Medicare beneficiaries when appropriate. CMS has established protocols for these ABNs, including the wording and the format. There are several basic requirements for a valid ABN:
the test which may be denied must be listed
the reason for possible denial must be given for each test;
the beneficiary must check either Option 1 or Option 2
the beneficiary must sign the ABN (if the patient is unable to sign the ABN themselves, the person responsible for the patient’s usual business affairs may sign);
the beneficiary must date the ABN.
The ABN must be available upon request by Medicare. “Blanket” or routine ABNs for Medicare beneficiaries are not allowed. ABNs should only be requested in situations where it is anticipated that Medicare may not pay for the test.
Diagnostic Documentation and ICD9 coding
The Balanced Budget Act (BBA) of 1996 amended the Social Security Act to require
that, where diagnostic or other information may be required for payment to be
made to an entity (e.g., laboratory, radiology), “The physician or
practitioner will be required to provide diagnostic information to the entity at
the time the service is ordered by the physician or practitioner.” The most
accurate way of providing this information is the use of ICD-9-CM coding at the
highest level of specificity.
When the physician or practitioner orders multiple tests or services, the
appropriate diagnosis should be linked to the tests being ordered for that
diagnosis.
If the test or service requested is subject to the limitation of liability
provisions and may be denied due to lack of medical necessity, Medicare
recommends that the physician or practitioner obtain a signed waiver of
liability (ABN, or Advance Beneficiary Notice) from the patient to protect the
billing entity from liability.
The centers for Medicare and Medicaid Services and the Office of the inspector General recognize that physicians and other authorized individuals must be able to order any tests that they believe are appropriate for the treatment or diagnosis of their patients. However, claims submitted for tests or services will only be paid if the service is covered, reasonable, and necessary for an individual patient given his or her clinical condition.
A standing order is an order from a medical provider requesting that specific lab work be performed on a specific patient on a set routine schedule. Although standing orders are generally discouraged, it is permissible under existing law to perform tests pursuant to standing orders executed in connection with an extended course of treatment.
In order to ensure the validity of such standing orders, consistent with federal and state requirements, Dayton General Hospital requires the following: