Billing Requirements

The following Medicare billing requirements will assist you to accurately fill out laboratory requisitions or submit a successful and complete laboratory order. When billing Medicare, the following information is always required. 

  • Patient's full name
  • Patient's gender
  • Patient's date of birth
  • Patient's phone number
  • Patient's full address
  • Ordering provider full name
  • Date and time of collection and fasting status
  • Who is to be billed (indicate Medicare)
  • Patient's Social Security Number (optional)
  • Insurance ID number (Medicare HIC # + Prefix or suffix character(s))
  • Marked Test(s) being ordered
  • Appropriate and valid ICD-10 for every test ordered
  • When indicated, a signed and dated ABN-with test(s) listed, reason(s) specified for possible denial and estimated cost of test(s) with the patient checking the option desired and the patient signing and dating the ABN.

This additional information is essential for accurate billing and collections.

  • Patient's Social Security Number

Medicare is very specific about what elements are required on an ABN for it to be considered valid. Absence of any of the required elements invalidates that ABN and is the same as no ABN at all. Medicare is also very specific about format and appearance of the ABN. Please utilize our ABN Request software to generate an ABN. A “blank” ABN may be generated from our ABN Request software to confirm formatting. The following must be completed on each ABN obtained:

  • Patient’s name
  • Date of birth or other unique identifier as Identification Number. Must not use Medicare number (HICN) or SSN.
  • Specific tests the patient was advised could be denied must be listed in the appropriate column.
  • The reason these tests may be denied must be listed in the appropriate column.
  • The estimated cost of the test(s), to the best of your knowledge, must be provided in the appropriate column.
  • Once the information is recorded, ask the patient to read, and then check Option 1, Option 2, and or Option 3. The patient must do this.
  • Patient must date the ABN.
  • Patient must sign the ABN.

The procedure for obtaining a Medicare waiver (ABN) is based on the current list of tests for which Medicare requires a specific ICD·10 code to consider payment. Please utilize our ABN Request software or refer to the Billing Guide to assist with determining which lab services require proof of medical necessity. Do not obtain a Medicare Waiver (ABN) for every Medicare patient, but only for those who may be held liable for the service.

Medicare Secondary Payor

Medicare Secondary Payer (MSP) refers to those instances in which Medicare does not have the primary responsibility for paying the medical expenses for a Medicare beneficiary.

All providers should screen Medicare patients to obtain correct health insurance information before submitting a primary claim to Medicare.

By completing the MSP Questionnaire to initially screen your Medicare patients, you will help reduce costs to the Medicare Program as well as administrative costs to your practice.

Requisitions provided to the laboratory should reflect accurate patient insurance information, including screening for Medicare Secondary Payer. Laboratory Patient Service Center employees will provide Medicare Secondary Payer screening when performing phlebotomy on Medicare beneficiaries. Physician offices that are unable to provide Medicare Secondary Payer screening are encouraged to direct their patients to our Patient Service Centers for this vital requirement of the Medicare Program.

ABN Form

References:
Medicare Part B 1999 Basic Billing Manual
Medicare B New, Issue 167 “Medicare Secondary Payer”
Hospital Manual – Section 295.1, 301-301.2 January 1999