IDENT
Type of Document:
Type of Policy:
Applicability:
Sponsor’s Dept:
Title of Sponsor
Title of Approving Official:
Date Released (Published):
Next Review Date
SUBJECT:
LAB COMP 100.004
Policy
Department
All
LAB
Adm.Director
Director of Laboratory
05/14/2015
05/14/2017
Custom Profiles
PURPOSE:
The purpose of this policy is to provide guidance to all University of Vermont Medical Center
(UVMMC) and billing personnel as to how Custom Profiles are created, maintained and discontinued.
POLICY STATEMENT:
Custom profiles permit physicians to establish their own test profile, consisting of a particular
group of tests, that they order frequently for their own patients. Physicians in certain specialties
often have such groupings for particular clinical situations.
The government recognizes the need for custom profiles that reflect a physician's test packaging
needs. However, the government expects the laboratory that constructs the custom profile to
provide a disclosure notice to the physician who uses a custom profile. This disclosure is called a
Physician Acknowledgement of Customized Profile.
By way of acknowledgement, the physician affirms the understanding that:
1.
2.
3.
The tests ordered are medically necessary and will provide the correct ICD-9
code for documentation.
Individual tests or a less inclusive profile should be ordered when not all of the
tests in the custom profile are medically necessary.
The Office of Inspector General (OIG) of the Department of Health and
Human Services takes the position that an individual who knowingly causes a
false claim to be submitted, may be subject to sanctions and other remedies
under civil, criminal or administrative law.
The Physician Acknowledgement of Customized Profile form includes the profile name, the test
components, the CPT codes billed, the patient price and the Medicare reimbursement amount.
This information ensures that the physician has adequate information to make a fully informed test
ordering decision and understands the implications of ordering a custom profile.
The Laboratory requests that the physician sign a Physician Acknowledgement of Customized
Profile when a custom profile is created per physician request and on an annual basis for as long
as the physician wishes to order the custom profile.
PROCEDURE:
1.
All Physicians are requested to sign a Physician Acknowledgement of Customized Profile
form if they request the laboratory to create a profile.
2.
On an annual basis, the Laboratory Marketing Specialist requests a printout from LIS
listing all physicians who use custom profiles.
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DISCLAIMER: Only the online policy is considered official. Printed policies should be compared with on-line document for accuracy.
3.
A Physician Acknowledgement of Customized Profile form is sent to each physician on
the list who has ordered the same profile at least three times in the past year. The form
describes the particular custom profile the physician has ordered the previous year and
requests that the physician signs the form and returns it to the laboratory.
4.
If a physician does not return the first form, then a second form is sent with a letter from
the Laboratory Compliance Specialist. The letter explains the importance of the
Physician Acknowledgement of Customized Profile form and again requests that the
physician sign and return the form.
6.
The Laboratory makes 2 attempts to obtain a Physician Acknowledgement of Customized
Profile. The laboratory’s efforts to obtain the Physician Acknowledgement of Customized
Profile is documented by the Laboratory Marketing Specialist and reported to the
Laboratory Compliance Specialist. The original paper version of the signed form will be
kept for 1 year. Documentation of the lab efforts and physician compliance will also be
stored electronically indefinitely.
MONITORING PLAN: N/A
REFERENCES:
OIG Compliance Program Guidance for Clinical Laboratories,
August 1998.
APPENDICIES:
1.
2.
REVIEWERS:
Janet Schroeter, MT (ASCP) Laboratory Compliance Specialist
Colleen Williams, MLT (ASCP) Laboratory Marketing Specialist
Kathy Nadeau, MT (ASCP) Laboratory Compliance Specialist
Monica Sullivan, Manager, Clinical Laboratory
Chuck Powden, Manager, Clinical Laboratory
Tim St. John, Manager, Anatomic Laboratory
Lynn Bryan, Manager, Lab Client Services and Customer Service
OWNER’S NAME:
Tania C. Horton, Administrative Director
Physician Acknowledgement of Custom Profiles
Follow-up letter to physicians regarding Custom Profiles
APPROVING OFFICIAL'S NAME:
Mark K. Fung, MD, Director of Clinical Laboratories
Printed on: 2/2/2016
By: %username%
DISCLAIMER: Only the online policy is considered official. Printed policies should be compared with on-line document for accuracy.
Printed on: 2/2/2016
By: %username%
DISCLAIMER: Only the online policy is considered official. Printed policies should be compared with on-line document for accuracy.
Appendix 1
PHYSICIAN ACKNOWLEDGMENT OF CUSTOMIZED PROFILES
You ordered the attached customized profile within the past year (2001). If you wish to continue using this profile,
please sign the acknowledgement and return it to the laboratory. As part of the Office of the Inspector General’s
compliance guidelines for laboratories, University of Vermont Medical Center laboratory must provide an annual
notice to each physician who orders customized testing.
By way of this acknowledgment, you affirm your understanding that:
1.
2.
You will order only tests that you believe are medically necessary.
You will order individual tests or a less inclusive profile when not all tests in a customized profile are
medically necessary for an individual patient.
You will provide an ICD9 code to document medical necessity for all tests included in the customized
profile.
The Office of the Inspector General of the Department of Health and Human Services takes the position
that an individual who knowingly causes a false claim to be submitted may be subject to sanctions or other
remedies under civil, criminal or administrative law.
3.
4.
Profile
TP1C
Thrombosis
Panel
Components
Protime
PTT
Cardiolipin AB
Dilute Viper Venom
Thrombin Time
Homocysteine
At3, Functional
Protein C, Functional
Protein S, Functional
APC Resistance
PTT 50/50 Mix
Factor 5 Leiden (Digestion)
(Extraction)
(Interpretation and Report)
(PCR)
(Separation)
CPT Code
85610
85730
86147(X2)
85613
85670
82131
85300
85303
85306
85730(2)
85611
83892
83890
83912
83898
83894
Patient Price
$17.00
$21.00
$153.90
$46.48
$35.00
$103.00
$75.00
$125.00
$110.00
$178.80
$53.00
$53.00
$53.76
$53.76
$53.76
$53.76
$1186.22
Medicare Reimbursement
$5.43
$8.30
$19.00
$13.22
$6.43
$14.78
$15.69
$17.62
$19.75
$16.60
$5.45
$5.54
$5.54
$5.54
$6.03
$5.54
$170.46
I understand these implications of ordering customized profiles and I request the creation and/or use of the above
stated customized profile(s).
Provider Name:
Provider Signature:______________________________________________ Date: ______________________
Please return signed form to Colleen Williams, Lab, Mercy 204. Contact me with any questions you have regarding
this matter. I may be reached at 847-9473 or Colleen.Williams@vtmednet.org.
CP tp1c template 2000
November 12, 2001
Printed on: 2/2/2016
By: %username%
DISCLAIMER: Only the online policy is considered official. Printed policies should be compared with on-line document for accuracy.
Appendix 2
April 2, 2001
Dear Dr.
The government expects laboratories that construct custom profiles in response to a physician’s request to provide
an annual disclosure notice to the physicians who use the custom panel. This disclosure is called a Physician
Acknowledgement of Customized Profile. The purpose of this acknowledgement is to guarantee that physicians
have adequate information to make a fully informed test ordering decision.
Our laboratory records indicate you have ordered the following customized profile of laboratory tests (see attached
sheet) during the past year. We have not received a signed Physician Acknowledgement of Customized Profile from
you. We ask that you sign the attached Acknowledgement and return it to the address indicated on the form.
Thank you very much for your assistance with our compliance program.
Sincerely,
Janet Schroeter
Laboratory Compliance Specialist
847-9435
Printed on: 2/2/2016
By: %username%
DISCLAIMER: Only the online policy is considered official. Printed policies should be compared with on-line document for accuracy.