LifeBridge Health - NORTHWEST HOSPITAL CENTER   GENERAL INFORMATION

Section 1.15 Medical Necessity

Federal and state low require appropriate documentation of the need for testing in order for a laboratory to perform and be reimbursed for that testing. Appropriate documentation requires several steps, including:

Hard Copy Orders

For inpatients, a physician’s note on the chart provides hard copy documentation of an order. That order must be transcribed by nursing staff and entered into the Cerner system to generate either a requisition or a label, which substitutes for a requisition.

For outpatients, a prescription form or other hard copy order form must accompany the patient or specimen to the laboratory. LifeBridge Laboratories will not accept requisitions from commercial laboratories such as Quest or Labcorp. The prescription form must be signed by a physician, physician’s assistant or nurse practitioner.

Medical Necessity

For inpatients, the law recognizes a physician’s request on a patient chart as documentation of medical necessity. The appropriate ICD9-CM code, which is generated at the end of the patient stay should also coincide with the testing which was ordered in order for it to be reimbursed.

For outpatients seen on campus, the same rules apply. The prescription must be accompanied by an appropriate ICD9-CM diagnosis code or a textual diagnosis which is generated by the physician writing the order.

Panels

Only those panels/profiles approved by HCFA may be ordered reimbursed. Available panels are orderable in the Cerner system and are on the Outreach requisition form. The law encourages ordering of individual tests based on medical necessity

Reflex Testing

Federal law allows the reimbursement of reflex testing (performance of a test not specifically ordered by a physician) if that reflex testing is considered medically necessary. All reflex and cascade testing performed by Northwest Hospital Center or its reference laboratories, has been reviewed by the Medical Executive Committee and is, therefore, deemed to be medically necessary.

Section 1.16 Medicare Fraud and Abuse

EFFECTIVE DATE: 04/04 SUPERSEDES: 04/02

DEPARTMENT HEAD APPROVAL:  NWHC Laboratory Medical Director, NWHC Laboratory Operations Manager

Northwest Hospital Center laboratory complies with federal law related to Medicare fraud and abuse, including the requirement of hard copy orders, the requirement of documented medical necessity, the appropriate use of ICD9-CM diagnosis codes and the limited use of test panels for ordering purposes.

The laboratory has developed a compliance plan and has in place appropriate monitors and checkpoints to assure compliance and rapid problem resolution.

The laboratory participates in Northwest Hospital Center Compliance Committee initiatives.

Section 1.17 Transporting Lab Specimens Via Pneumatic Tube System

The following laboratory specimens may be transported to the laboratory via pneumatic tubes as long as the proper procedures are followed:

• Venous blood samples in Vacutainer tubes that have not had the stopper removed
• Blood culture bottles (maximum of 2 blood culture bottles per carrier)
• Chlamydia / GC transport tubes
• Cultures on swabs
• Stools in securely sealed cups or occult blood on cards only
• Urine specimens (In urine transport tubes only – no cups)
• Blood gas specimens in a sealed bag on ice

The following specimens should not be transported to the laboratory via pneumatic tube:

• Venous blood samples in Vacutainer tubes that have had the stopper removed to fill the tube
• CSF or other body fluid specimens
• Urine specimens in cups
• Specimens in formalin

1. Procedure:
   1. Pack appropriate specimen(s) in biohazard bag and seal.
   2. Place specimen that has been placed in the sealed biohazard bag into a "Zip N Fold" carrier liner and seal.
   3. Place specimens in a tub
   4. Secure both latches on the carrier.
   5. Place carrier in the tube station.
   6. Select the laboratory as the destination and send. (Note: The ER7 six inch tube line is dedicated to the laboratory, it is not necessary to select a destination)
2. Procedure Notes
   1. Refer to the Blood Transfusion Procedure in section 5.6 of this manual for instructions on requesting blood components for transfusion via the pneumatic tube system.
   2. Refer to the Pneumatic Tube Policy in the NWHC Policy Manual for further instructions on use of the pneumatic tube system.
   3. Specimens that leak or are damaged during transport must be recollected.
   4. Carriers that have transported leaking specimens that were not contained by the "Zip N Fold" bags must be disinfected with Coverage^TM spray or an equivalent product and then forwarded to SPD for gas sterilization.
   5. The laboratory will notify the person who collected the specimen if there is a problem. A new specimen may be requested as needed.
   6. If a the specimen leaks outside of the "Zip N Fold" bag and also leaks out of the carrier, the tube system must be decontaminated. Call the Laboratory immediately at ext. 5-5902 to report the leak / spill.
   7. Blood gas specimens must have the needle removed and safely discarded before sending the specimen to lab on ice.

Section 1.18  Provocative Laboratory Tests Requiring Timed Collections and Special Handling of Patients or Specimens

Introduction:

A number of tests of function or responsiveness involve administration of some agent to a patient and collection of specimens at specified intervals. These tests are ordered infrequently, usually involve several hospital departments (pharmacy, laboratory, nursing service, etc.) and often require scheduling, patient preparation or processing of samples.

At times, there may be several versions of a given test so that consultation with a physician or pathologist may be necessary. Sometimes, a more recent version of a test will be desirable. Since the laboratory does not have written procedures for these unusual tests and must select a method for specimen collection as the need arises, ordering physician, nurses, PA’s and clerks must follow the general protocol that follows. The earlier that communication occurs with the laboratory, the more likely the test will be performed correctly!

Whenever these tests are ordered, the following system must be used to assure proper and timely performance of the test, as well as avoiding unnecessary or futile work. The tests below comprise a partial list of these provocative tests. The processing methodology will be identical at all LifeBridge Health sites.

• ACTH stimulation test (2-day, 3-5 day, 1hr, 8hr)
• Clomiphene stimulation test
• Clonidine suppression test
• Calcium-pentagastrin stimulation test
• DDAVP stimulation test
• Dexamethasone supression test (high dose, low dose, overnight)
• Glucagon stimulation test
• Glucose tolerance tests (other than the oral glucose tolerance tests described in section 2.6 of this manual)
• Gonadotropin releasing hormone stimulation test (GnRH)
• HCG stimulation test
• Histamine stimulation test
• Insulin tolerance test
• Lactose tolerance test
• Metyrapone suppression test
• Parathyroid hormone decrease (intraoperative) Provocative test list continued:
• Pentagastrin stimulation test
• Secretin stimulation test
• Sweat test
• Tolbutamide tolerance test
• Triple bolus test (TRH, GnRH, insulin)
• Water deprivation test