CMS Pub. 100-04, ch. 16, § 90.3

All test codes should be processed and stored in history as they are submitted. That is, if

tests are submitted as individual CPT codes together and paid as a panel (see §90), the

claim history data will reflect the individual codes and the panel used in pricing. All tests

must maintain their identity as billed.

Prior to January 1, 1998, automated panel codes were adjudicated only on a line-by-line

basis with application of the correct coding initiative (CCI) edits for duplicate detection.

As of January 1, 1998, when individual automated test codes are received, A/B MACs

(A) and (B) did not combine them into panels for processing. The only instance in which

they should be panel codes is when they were coded as such on the claim.

1 CPT code 83718 is billed with Organ/Disease Panel 80061 but is not included in the AMCC bundling.

Beginning January 1, 2018, Medicare does not recognize automated test panels, unless a

panel has its own CPT code, as described in section 90.2.

A/B MACs (A) and (B)

1. Deny Duplicates. Deny duplicate services detected within the same processing cycle

or stored in an automated history file. Consider claims that match on the following items

as duplicates

a. The service was performed by the same provider,

b. For the same beneficiary, and

c. For the same date of service.

2. Medical Necessity. Determine medical necessity. This process permits the

identification of CPT codes subject to local medical review policies.

3. Process Claims. For claims with dates of service prior to January 1, 2019, the

processes shown below (A-K) should be followed to price and pay claims for automated

panels (as defined in HCPCS) and individual tests. This does not replace or abridge any

current procedures in place concerning the adjudication of claim. This is a general

procedure for combining these services to attain the lowest pricing outcome. This display

is an example only. System maintainers have the flexibility to vary these procedures as

long as they attain the same result.

A. Unbundle all panels to single lines representing individual automated multi-channel

chemistry (AMCC) tests, and identify duplicate tests within the claim. On

concurrently processed claims, determine the total amount payable based on the

combination of all AMCC tests billed by the same laboratory, for the same

beneficiary, and for the same date of service.

B. Check history for laboratory AMCC services provided by the same provider, to the

same beneficiary, on the same day. Unbundle any panels. Identify duplicate

services. Aggregate all nonduplicate services for pricing (include the submitted

charge and paid amounts for both individually or paneled billed claims). If a single

organ disease panel or a single chemistry panel contains the only AMCC test claims

for that date of service, adjudicate as billed.

C. Compare each line’s submitted charge to the fee schedule for that code (including

automated tests retrieved from history).

D. Sum the comparisons of the line by line.

E. Obtain the fee for all AMCC tests as a panel including all services in history. If organ

disease (OD) panels are involved, this amount will include fees for nonautomated

tests included in the OD panel.

F. Carry forward the lesser of items D or E.

G. For steps A-C above, include the following calculations to price the claim by locality,

using the fee schedule amount for each locality, when one or more test has been

referred to another laboratory for processing:

Use the total number of allowable AMCC tests (both referred and nonreferred) to

calculate the amount payable for each test. For example, if three tests are performed

within the A/B MAC (A)’s or (B)’s jurisdiction, and two are referred to another

laboratory for processing, first determine the amount payable for the five tests in each

payment jurisdiction. Divide the total fee schedule amount for all tests being priced by

the total number of allowable AMCC tests (in this example, five tests). The result is the

unit price for each test. Multiply this result by the total number of AMCC tests

performed within each pricing jurisdiction. (In this example, three tests were performed

in jurisdiction 1 and two tests were performed in jurisdiction 2). Repeat this process for

each pricing jurisdiction. In this example, there are two pricing jurisdictions. In

jurisdiction 1, the amount payable is calculated by dividing the total fee schedule amount

for jurisdiction 1 by five, and multiplying the result by three. Similarly, the amount

payable for jurisdiction 2 is calculated by dividing the total fee schedule amount for

jurisdiction 2 by five, and multiplying the result by two. Sum the two results (i.e.,

jurisdiction 1 amount + jurisdiction 2 amount). Compare this calculated amount to the

submitted charges for the AMCC tests to determine the amount payable. (The amount

payable is the lower of the fee schedule amount versus the submitted charges.)

H. Carry forward the lesser of the fee schedule amount versus the submitted charges, as

determined in item G.

I. Subtract from item H any previous laboratory AMCC test (individual or paneled) or

organ disease panel containing automated test payments. If nothing is payable on the

claim, allow it with no payment.

J. The amount payable is the total payable based on the combination of current and

previously processed claims, less the total amount paid on the previous claim(s).

K. If a claim is a CLIA reject from the CWF, recycle that claim through the payment

process to recalculate payment.

(NOTE: These calculations are provided as an example only. A/B MACs (A) and (B)

and shared system maintainers have the flexibility to vary these procedures as long as

they attain the same result.)

If none of the AMCC tests have been referred to another laboratory for processing, A/B

MACs (A) and (B) should exclude item G in calculating the amounts payable for

individual AMCC tests and AMCC panels.