UHC lab test code requirement delayed

Wednesday, December 2, 2020

United Healthcare (UHC) recently announced that it is delaying the implementation date of its unique laboratory code policy. The policy, which was originally set to go into effect January 1, 2021, will be delayed until January 1, 2022.

The policy will require in-network hospital, freestanding and outpatient laboratory claims to contain a unique code for most lab testing services in addition to standard CPT® codes. Hospitals and laboratories will need to register lab-specific test codes with UCH before December 1, 2021. The policy will apply to UHC’s commercial, Medicare Advantage, and community plan health products. Absence of the lab-specific test code information will result in claim denials.

Industry stakeholders, including the American Hospital Association (AHA) and NAHRI Advisory Board members, have raised concerns about the timing of UHC’s policy and how it appears to conflict with HIPAA’s administrative simplification transaction and code set standards.

Under HIPAA, provider and payer organizations are required to use standard content, formats, and code sets. HIPAA considers CPT codes the standard code set for outpatient services, including lab tests. Because hospitals and laboratories are HIPAA-covered entities, they are required to use CPT codes to report lab services on outpatient claims. Payers are also governed by HIPAA and are required to appropriately use approved code sets.

“This is a call to action for NAHRI members as far as I am concerned,” says NAHRI Advisory Board Member Valerie Rinkle, MHA, CHRI, regulatory specialist with HCPro. “From my perspective, it is time to make the HIPAA transaction sets really mean something when it comes to reducing administrative waste in the healthcare system.”

UHC’s policy also appears to go against the National Uniform Billing Committee’s (NUBC) own policies. UHC is directing hospitals and laboratories to report the lab-specific test code in Form Locator (FL) 43 on paper UB-04 claims and using NTE segment loop 2400 (service line number) in electronic claims. However, those fields can’t be used for that, according to the organizations responsible for maintaining paper and electronic claim forms. According to the UB-04 manual, FL43 can only be used to report revenue code descriptors and other specific information approved by the NUBC. X12 Inc., the organization that maintains electronic claim formatting standards, specifies that NTE segment loop 2400 is for third party organization notes and shouldn’t be completed by provider organizations.

“I believe the delays we’re seeing are primarily a result of behind the scenes conversations that both the AHA/NUBC and the multi-state hospital associations have had with UHC, although perhaps the individual provider pushback UHC received helped somewhat,” says NAHRI Advisory Board Member John Settlemyer, MBA, MHA, CPC, CHRI, assistant vice president of corporate revenue management/CDM operations at Atrium Health in Charlotte, North Carolina. “I would say the biggest message is that providers and labs need to be engaging and connecting with NUBC and their state associations to keep the heat on this so that it is ultimately outright retracted.”

UHC maintains that the policy supports improved patient care and affordable products. However, along with compliance concerns, the policy increases administrative burden and may ultimately have a negative effect on patient care and affordability.

“For many years, the major insurers have been pushing outpatient providers to use their contracted facilities for imaging and laboratory services as a cost-control method. This requirement to use additional codes seems to be their attempt to add another arrow in their quiver,” says NAHRI Advisory Board Member Ronald Hirsch, MD, FACP, CHCQM, CHRI, vice president of physician advisory services at R1 RCM in Chicago. “But each new requirement seems to be unilateral, benefitting the payer but adding cost, inconvenience, and possibly harm for the provider and patient. The delay does not change the equation and pressure on UHC to permanently rescind this should continue.”