THIS PAGE PRESENTS THE MEDICARE RULES AND LINKS TO OTHER SPECIFIC
RULINGS ON MEDICARE BLOOD TESTING REIMBURSEMENT AND SERVICES.
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Reimbursement and Coverage
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BloodBook.com provides on this
page, as a service to our visitors, Medicare reimbursement information
pertaining to Blood testing and some other limited Blood services. Medicare
and Medicaid will pay for Blood testing, therefore, it is certain that this
is an important topic. We would like to make this a more comprehensive
presentation, however, the Medicare rulings change often. These changes
affect the reimbursement schedules and differ substantially by state,
county, date, eligibility and qualification requirements. You must
know the rules and follow the rules if you expect Medicare to pay your
Before you commit to anything,
be certain as always, to check with Medicare at the
numbers that we have provided below.
Under the Social Security Act
which established the Medicare insurance program, only Blood testing
necessary for treatment or diagnosis of illness or injury will be
reimbursed. Medicare will not pay for checkups or most Blood screening
tests. Blood testing laboratories have been assigned the responsibility of
certifying that the Blood testing that they perform is in compliance with
current Medicare guidelines.
In accordance with those
Medicare requirements, your chosen Blood testing laboratory will probably
require most of the following documentation before the Blood procedure or
test will be performed:
Identification of the
To be certain of reimbursement, the chosen Blood testing laboratory must be
able to identify a qualified provider as defined by Medicare.
There must be a reason
for the Blood test or procedure.....
The provider must complete some required paperwork, fill out the check boxes
on a "requisition," to document the reason for ordering the Blood testing.
Title XVIII of the Social Security Act, section 1862(a)(7) excludes
routine physical checkups (including Blood testing performed in the
absence of signs or symptoms) from the Medicare program. Screening is
defined as diagnostic procedures performed in the absence of signs or
symptoms. Screening is often performed based on patient age and/or
family history. While BloodBook.com recommends such examinations and
tests as good medical practice, they are not covered
The diagnosis code indicated on the claim should reflect the reason for
performing the requested Blood laboratory test.
Limited coverage Blood
The Health Care Finance Administration (HCFA) requires Medicare carriers
to establish policies to ensure the medical necessity of services being
paid for by the Medicare program. Carriers in your local area have the
authority to establish a list of Blood tests and test procedures which
may require medical documentation in order for reimbursement to take
place. Carriers will then only approve payment for those particular test
procedures when they have determined them to be medically necessary for
the patient. As a result, a claim submitted without a diagnosis code
that indicates medical necessity based upon the local carriers'
policies, will result in denial of payment for those services. You will
then have to pay for these Blood tests out of your own pocket.
Payment for limited coverage tests will be denied unless the claim is
accompanied by that appropriate diagnostic code. The Medicare program
will only allow the laboratory to bill the patient for denied services
if an Advance Beneficiary
Notice is completed, the appropriate places checked and signed by
the patient, and forwarded to the Blood testing laboratory.
If your chosen Blood testing laboratory does not receive an acceptable
diagnosis on the requisition form, or a signed
Advance Beneficiary Notice, the office account of your physician may
be charged for those denied services and your failure to provide the
appropriate information will be documented.
The Health Care Finance Administration (HCFA) requires that physicians'
offices have a patient sign an Advance Beneficiary Notice Form
when a patient has a Blood screening test performed by a Blood testing
laboratory. That Advance Beneficiary Notice should be submitted to the
Blood test laboratory with the Blood test request form.
The Advance Beneficiary Notice is intended to inform the patient that
Medicare will not pay for services that Medicare determines to be not
reasonable and necessary under Section 1862(a)(1) of the
Medicare Law. If Medicare determines that a particular service,
although it would otherwise be covered, is not reasonable and necessary
under the Medicare program standards, Medicare will deny payment for
that service. Thus, payment for those screening tests becomes the
responsibility of the patient. You will then have to pay for these Blood
tests out of your own pocket.
Medicare Advance Beneficiary Notice Form
Medicare Blood Transfusion Information
Information on the Advance Beneficiary Notice Quick Reference Guide is
available from the HCFA web site HERE.
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last updated 03/10/2013