AHA: UHC’s new lab test code requirements create unnecessary burden

UnitedHealthcare’s (UHC) plan to require in-network, freestanding and outpatient laboratory claims to contain a unique code for most lab testing services is poorly timed and poses significant implementation hurdles, the American Hospital Association (AHA) said in an August 14 letter.

Effective January 1, 2021, UHC will require the unique, lab-specific test codes in addition to standard CPT® codes. Hospitals and laboratories will need to register lab-specific test codes with UHC before December 1, 2020. 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.

The AHA raises several concerns about the new policy in its letter and points out that organizations have not had enough time to prepare. With resources already strained due to the ongoing novel coronavirus (COVID-19) pandemic, some organizations might not be able to comply, the AHA cautions in its letter.

The new policy may conflict with HIPAA’s administrative simplification transaction and code set standards, the AHA said. Under HIPAA, provider and payer organizations are required to use standard content, formats, and coding. 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 utilize approved code sets.

In addition, 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 National Uniform Billing Committee (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.

Hospitals and laboratories should discuss internally with legal and managed care to evaluate whether to file a formal objection with UHC and should also consider filing a formal HIPAA code set violation through the Administrative Simplification Enforcement and Testing Tool (ASETT), says John D. Settlemyer, MBA, MHA, CPC, CHRI, assistant vice president, corporate revenue management/CDM operations, at Atrium Health in Charlotte, North Carolina, and a NAHRI Advisory Board member.