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Question from a Member

Tuesday, July 11, 2017   (1 Comments)
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Are other physician organizations billing Medicare for Hep C screening tests (G0472)? If so, I’m wondering how your lab system is set up. Are you able to result this test in the office where the blood is collected, or do you have to send it off to an off-site lab (whether owned by your organization or independent) for processing?

In our organization, many of our more rural clinics don’t have these lab processing capabilities on-site, therefore the clinic where the blood is drawn is not necessarily where the processing will occur. We have always billed each service – blood draw and lab – in the physical location at which each was performed. However, our patients have begun to receive bills for the blood draw (36415) portion of this test in these cases, as Medicare is denying as PR49. Our patients understand this screening service to be covered under Medicare. When I contacted NGS, I was told that the only way for the 36415 charge to pay under the Hep C screening benefit is for it to be submitted on the same claim as the G0472 code. Since these two portions are done in two different physical locations though, with the processing sometimes being performed at a reference lab for which we can’t bill at all, we did not feel this was possible.

The response I received from NGS was that our practice is abnormal and that CMS expects the specimen to be processed in the location where it was drawn. Therefore, NGS has devised a “workaround” for us, whereby we can bill both charges with the location of where the lab was processed. This doesn’t seem right to us, and doesn’t help us in cases where the reference lab is billing for the G0472 rather than us, and we are only billing the 36415. I’m just wondering if anyone else is seeing this and if our process truly is as unusual as NGS is indicating.

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Carl Langhoff says...
Posted Thursday, July 13, 2017
Good morning, We are experiencing the same denial trend and your process isn't as unusual as NGS has indicated. I am surprised to hear the "workaround" that NGS has proposed as when I contacted them I was informed that there is no way that 36415 would pay with the Hep C screening diagnosis. I was anticipating that there would be an update to the lab NCD manual in the next year to address this issue.

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