Latter day adjustment pathology services in Medicare 012-40020050

Effective 30 October 2011, the payment system automatically applies restrictions between pathology items according to the patient episode (date of request (DOR)/PA line). This includes some time dependent restrictions and some item association restrictions.

LDAs must be used for all occasions when 6-RST ADJ displays. Use of processing indicator (PI) PI 58 only applies when an LDA cannot be performed. When using PI 58, PI 42 must not be used to override a restriction until PI 58 has been applied to the item.

The Process page provides a table showing how to action pathology claims with 6-RST ADJ message.

When the 6-RST ADJ message displays for pathology services wherever possible an LDA must be performed. Although there are some occasions using the LDA system is not possible and PI 58 can be used to adjust benefit for those pathology services.

Instances where an LDA is not possible are:

• the patient episode has been claimed using different claiming channels, such as bulk bill and patient claims
• the claim has been lodged through the Simplified Billing/ECLIPSE channel
• the Medicare benefit cheque for the previously claimed services is unpresented
• bulk bill services for the same patient episode have been claimed as in and out of hospital services
• the patient episode has been bulk billed by 2 different pathology providers

When using PI 58 and coning applies to the patient episode, the adjustment amount must be calculated for all services in the whole episode so that only the adjusted amount for the 3 items to which coning applies is paid.

PI 42 must not be used to override a restriction between 2 restrictive services until after PI 58 has been used as the restrictive item may have the highest schedule fee.

The patient episode coning rule applies to pathology tests requested by general practitioners (GP) but not to pathology tests requested by specialists or consultant physicians (speciality code ranges: 001-099 and 800-899), dentists or in-hospital services.

A patient has been paid 3 separate pathology claims, all services have been requested by a general practitioner (GP) and the system has applied coning adjustments so only the 3 items with the highest schedule fee have been paid. A new pathology claim has been lodged for an item that restricts with an item on history and the item in the new claim has a higher benefit. As the Medicare benefit cheques have not been presented, an LDA is not possible.

The adjustment amount must be calculated based on the 3 items (that are not exempt from coning) with the highest schedule fee.

LDA for pathology services where coning doesn't apply include:

• in-hospital services
• services requested by:
• specialists
• consultant physicians
• dentists

LDAs must be performed for restrictions between bulk billed pathology items rendered by the same practitioner in separate manual and electronic claims.

For example:

• item 66695 was claimed in a patient episode requested by a specialist in bulk bill claim identification (ID) K0014
• the same pathologist has subsequently claimed item 66698 in bulk bill claim ID K0022, also requested by a specialist
• when assessing claim ID K0022, item 66698 comes up as restricting with item 66695 in claim ID K0014 on the patient's history
• the return message 6-RST ADJ is displayed as item 66698 has a higher schedule fee

None of the services are endorsed as rule 3 (R3) exempt or S4B3 services. An LDA is required to pay the difference between items 66695 and 66698.

The patient episode coning rule does not apply to pathology tests requested by specialists or consultant physicians (specialty code ranges: 001 - 099 and 800-899), dentists or in-hospital services.

The Process page provides a table showing how to action non-coned patient episodes for bulk bill LDAs.

LDAs must be performed for restrictions between bulk billed and patient claim pathology items rendered by the same practitioner in separate manual and electronic claims. The only exception is simplified billing claims.

The patient episode coning rule applies to pathology tests requested by general practitioners (GP) for out of hospital services.

Bulk bill claim

• item 65070 has been claimed in a patient episode requested by a general practitioner (GP) in bulk bill claim ID A0013
• the same pathologist has subsequently claimed item 65096, also requested by a GP for the same date of request (DOR)
• when assessing claim ID A0024 item 65096 restricts with 65070 in claim ID A0013 on history
• the return message 6-RST ADJ is displayed as item 65096 has a higher schedule fee

None of the services are endorsed as rule 3 exempt or S4B3 services. An LDA is required to pay the difference between items 65096 and 65070.