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Compliance: Laboratory Compliance

Our regulatory compliance program ensures that UC Irvine Medical Center's clinical laboratories, its officers, managers, employees and independent contractors who engage in the sale, performance and billing of laboratory services maintain the business integrity and honesty required of a participant/supplier in federally funded healthcare programs.

Through this compliance program, UC Irvine Health Pathology Services is committed to improving the quality, efficiency and consistency of laboratory services. We also promote compliance with the complex legal requirements, such as ensuring that:

  • Only laboratory services that have been provided are billed
  • Services are accurately reported
  • The medical necessity for services billed is documented

Clinical Consultant

If you require assistance in ordering the appropriate laboratory tests for your patients, please contact the laboratory at 1-888-UCI-LABS.  Your call will be directed to the appropriate medical or scientific director to assist you.

Laboratory Compliance Requirements

Advanced Beneficiary Notice (ABN)

Medicare rules prohibit the laboratory from billing the patient for laboratory tests for which the ICD-10 code(s) indicated by the provider do not support “medical necessity” — unless an Advance Beneficiary Notice (ABN) has been properly signed by the patient.

It is the provider’s responsibility to ensure that the ABN is signed and sent to the clinical lab. Our goal is to assist you in complying with this requirement. If your office would like help to determine whether or not an ABN should be provided, please call 714-456-1696.

If your office needs help in assigning correct ICD-10 diagnosis codes, please call 714-456-1696. In addition, the confidential compliance hotline can be reached at 1-888-456-7006.

View our ABN Information brochures (password protected):

Education & Training

Complete your Clinical Laboratory Compliance Training at Media Lab Inc. ›

Resources

Services

Visit the UC Irvine Health Pathology Services Manual website for test CPT codes and contact information at http://www.pathology.uci.edu/PathologyServicesManual/results.asp ›

Notification to licensed providers ordering lab tests

The UC Irvine Health Clinical Laboratories are committed to abiding by all applicable laws, rules, and regulations. The clinical laboratory demonstrates this commitment by acting ethically, honestly and with integrity in their billing practices. As part of this commitment, we are sending you this critical information.

Medical necessity

Medicare will pay only for tests that meet the Medicare coverage criteria, and are reasonable and necessary to treat or diagnose an individual patient. Learn more about:

Test panels, custom profiles and reflex testing

If all the tests in a multi-test panel are not medically necessary, a physician is expected to order only the individual tests needed to treat the patient.

The UC Irvine Health Clinical Laboratory does not offer custom panels, only CPT-coded panels.

Reflex testing is defined as any test ordered/performed as a result of an initial test and the corresponding rule logic exists in some laboratory areas.

The laboratory test list can be found at http://www.pathology.uci.edu/pathologyservicesmanual/results.asp 

Tests that cannot be performed

Claims for reimbursement are submitted only for tests that have been both ordered and performed.

If this laboratory receives a specimen without a test order or with an ambiguous order that can be subject to multiple interpretations, the ordering physician will be contacted to determine what test(s) are to be performed before testing is conducted or a claim for reimbursement submitted.

Direct billing and lab fee schedules

Direct billing by the laboratory is required for physician-ordered Medicare reimbursed laboratory tests.

If a hospital laboratory performs a test referred by a physician, only the laboratory may legally bill Medicare for the test.

View the Medicare fee schedule for laboratory tests at http://www.cms.hhs.gov/FeeScheduleGenInfo/ 

Clinical consultant 

If you require assistance in ordering the appropriate laboratory tests for your patients, please contact the laboratory at 1-888-UCI-LABS. Your call will be directed to the appropriate Medical or Scientific Director to assist you.

Physician responsibility

A provision in the Balanced Budget Act of 1997 mandates that effective Jan. 1, 1998, physicians who order diagnostic tests must provide the supplier of such services all diagnostic or other medical information required in order for Medicare payment to be made to the supplier.

Compliance Tips

View our latest tip sheets ›

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