Annual Notice to Physicians
19 July 2021
Dear Northern Light Laboratory Client:
The Office of the Inspector General (OIG), in its Guidance for Clinical Laboratories, believes that labs are in a unique position to be able to educate their clients by providing annual written notice with the following important information:
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Organ or disease related panels will only be paid when all components are medically necessary;
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The OIG takes the position that an individual who knowingly causes a false claim to be submitted may be subject to sanctions or remedies available under civil, criminal, and administrative law;
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Medicaid reimbursement amounts will be equal to or less than the amount of Medicare reimbursement. A link to the 2016 Clinical Laboratory Fee Schedule (in both CSV and Excel formats) can be found by visiting this URL: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched/index.html
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Using a customized profile may result in the ordering of tests which are not reasonable or necessary and will not be covered by Medicare;
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Medicare coverage is limited to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury and are within the scope of a Medicare benefit category. National coverage determinations (NCDs) are made through an evidence-based process, with opportunities for public participation. In the absence of a national coverage policy, an item or service may be covered based on a local coverage determination (LCD). All test orders that do not satisfy NCD or LCD medical necessity guidelines must be accompanied by a properly executed Advance Beneficiary Notice (ABN). Links to the current National and Local Coverage Determinations can be found at the following websites:
Lab National Coverage Determinations (NCDs) Alphabetical Index: https://www.cms.gov/medicare-coverage-database/indexes/lab-ncd-index.aspx
Lab Local Coverage Determinations (LCDs) Alphabetical Index (enter as a guest doing business in Maine/select Medical Policy & Review/Medical Policy Center/View a list of active LCDs for your region): https://ngsmedicare.com/ngs/portal/ngsmedicare/
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Heavy Metals LCD
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Federal law requires that a clinical consultant be available in all clinical laboratories. If you have any questions regarding the appropriate choice of lab tests or need consultation, please call Orin W. Buetens, MD, Medical Director at (207) 973-7617.
Should you have any questions or need additional information regarding lab testing, please call Jen Long, NLL Client Support Representative, at (207) 944-9970. For compliance questions or concerns, please call me at (207) 973-7649.
Kind regards,
Dayna M. Emerson MS, RD, LD, CHC, CACO
Compliance & Privacy Officer
Compliance & Internal Audit
Northern Light Laboratory
Direct: 207-973-7649
e-mail: dmemerson@northernlight.org
Medicare National Coverage Determinations (NCD) and Applicable ALI Test Options |
NCD |
ALI Test |
Alpha-fetoprotein |
AFP |
Blood Counts |
CBC |
HM |
HGB |
HCT |
PLT |
WBC |
Blood Glucose Testing |
GLU |
Carcinoembryonic Antigen |
CEA |
Collagen Crosslinks, any Method |
NTX |
Digoxin Therapeutic Drug Assay |
DIGO |
Fecal Occult Blood Test |
Occult Blood |
Gamma Glutamyl Transferase |
GGT |
Glycated Hemoglobin/Glycated Protein |
HGBAG |
Hepatitis Panel/Acute Hepatitis Panel |
HEP 1 |
Human Chorionic Gonadotropin |
BHGC |
Human Immunodeficiency Virus (HIV) Testing (Diagnosis) |
HIV |
Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) |
HIVPCRQ |
Lipid Testing |
HDL 2 |
CHOL |
HDL |
LDL |
TRIG |
Partial Thromboplastin Time (PTT) |
PTT |
Prostate Specific Antigen |
PSA |
Prothrombin Time (PT) |
PT/INR |
Serum Iron Studies |
IRON |
FERR |
TRNSF |
BLOCK 3 |
Thyroid Testing |
TSH |
T3 or T4 update |
T4 |
T4, free |
Tumor Antigen by Immunoassay - CA 125 |
CA125 |
Tumor Antigen by Immunoassay - CA 15-3/CA 27.29 |
CA153 |
CA 27 29 |
Tumor Antigen by Immunoassay - CA 19-9 |
CA199 |
Urine Culture, Bacterial |
C URINE |
UA-REFLEX |
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Medicare Local Coverage Determinations (LCD) and Applicable ALI Test Options |
LCD |
ALI Test |
B-type Natriuretic Peptide (BNP) Testing |
PROBNP |
RAST Type Tests |
IGE |
Allergy testing |
Urine Drug Testing (as of 12/01/15) |
UDR |
Vitamin D Assay Testing |
VIT D 25 |