A certain commercial payer has indicated that they will be requiring that providers/ institutions/ independent laboratories provide their test/ order code for certain clinical and anatomical pathology services in SV101-7 or SV202-7.
The Situational Rule for these reads the same:
Required when, in the judgment of the submitter, the Procedure Code does not definitively describe the service/product/supply and loop 2410 is not used.
OR
Required when SV101-2/ SV202-2 is a non-specific Procedure Code. Non-specific codes may include in their descriptors terms such as: Not Otherwise Classified (NOC); Unlisted; Unspecified; Unclassified; Other; Miscellaneous; Prescription Drug, Generic; or Prescription Drug, Brand Name.
If not required by this implementation guide, do not send.
The submitter does not feel that the AMA/ HCPCS Description of the associated HCPCS/CPT codes are insufficient for the payer to determine the service rendered. Additionally, the procedure codes impacted by the program are not unlisted/ N.O.C./ unclassified/ et cetera.
Is it appropriate for the commercial payer to require this test/ order code be supplied despite the provider/ institution/ reference laboratory meeting the criteria of the Service Section Description Field?
An example would be as follows:
--> CPT Code 83516, "Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method,"
--> Institutional specific description of "ANTI GLIADIN, IGG"
--> Institutional test/ order code "ADGPG"
In SV202-7 [or SV101--7] an override of
--> *LABADGPG" instead of standard institutional description of "ANTI GLIADIN, IGG"
The situational rules for both SV101-7 and SV202-7 specify that the elements are to be used based on the judgment of the submitter. A payer cannot require a submitter to use these elements. The RFI question refers to the payer asking or requesting this data, a submitter can send it, but a submitter cannot be compelled to send it. If a submitter judges that additional information is needed, the elements may be used to send the information.