“I’m from the Government, and I’m here to help.”

“I’m from the Government, and I’m here to help.”

Across the nation, clinical laboratories struggle to correctly interpret and follow the new National Correct Coding Initiative (NCCI) guidelines that took effect on Jan. 1. A financial disaster lies ahead for many labs.

“The denials are very high right now and those denials are nationwide,” stated Kyle Fetter, Executive Vice President and General Manager of Diagnostic Services for San Diego-based XIFIN. “Even if we consider only molecular tests in tier 1 and tier 2, there are many labs that are not getting paid for these tests. I would estimate that the effect of the changes NCCI made is anywhere from 40% to 100% of the revenue for these clinical labs.”

This negative development is not getting wide play in the lab industry. It is one more financial hit to clinical labs. Moreover, this is one more example of federal government ham-handedness in how it handles coding/billing and reimbursement for clinical lab tests. Many of you know about these past events:

  • Jan. 1, 2013: New molecular test CPT codes are introduced. Medicare administrative contractors (MACs) were unprepared to process claims. Some labs got no payments for these tests until May and June of 2013. (See TDR, Apr. 15, 2013.)
  • Apr. 1, 2014: The Protecting Access to Medicare Act (PAMA) includes specific steps CMS is to take to grant coverage for new advanced diagnostic laboratory tests (ADLTs) and establish a market price. Effective steps to implement this section of PAMA and timely action have often been lacking.
  • 2017-18: First PAMA-mandated reporting of private payer lab test price data. Critics charge that CMS created a final rule that games the incoming data so as to skew the results in a manner that would generate a much lower Medicare Part B Clinical Lab Fee Schedule than would result from a true and accurate market study consistent with the language of the PAMA law.
  • Jan. 1, 2019: New NCCI guidelines that are confusing and conflict with existing federal laws/regulations and coding requirements of the American Medical Association.

Maybe this is what President Ronald Reagan meant when he often said, “The nine most terrifying words in the English language are, ‘I’m from the government, and I’m here to help.’”

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