The Centers for Medicare & Medicaid Services (CMS) is responsible for administering the Medicare program throughout the United States. In order to ensure that services paid for by the Medicare program are indeed medically necessary, CMS has identified laboratory tests that require medical necessity documentation. These are called National Coverage Determinations or NCD’s. CMS also authorizes local carriers to establish their own list of tests which are called Local Medical Review Policies (LMRP’s) or limited coverage tests.
Medicare carriers have developed systems using ICD-9 diagnosis codes to prevent the payment of claims they determine are not medically necessary. Under these policies, NCD’s and LMRP’s, the patient’s diagnosis and the policies determine medical necessity. It is critical that the ICD-9 code used for ordering laboratory services be consistent with the documentation in the patient’s medical records so that the medical necessity information is clear and apparent in the event of a post payment review. The ICD-9 code used must be specific to a particular patient and the laboratory tests ordered by the physician for that date of service.
Physicians should only order tests that are medically necessary in diagnosing or treating their patients, and must be certain to enter the appropriate and correct ICD-9 code(s) in patients files and on the test request forms. Always have the patients sign and date an Advance Beneficiary Notice (ABN) if they believe the service is likely to be denied, unless the physician is willing to pay for the service.If a physician does not submit an ICD-9 for a limited coverage test, Ally Clinical Diagnostics will contact the physician’s office to ask for a copy of a properly executed ABN or a diagnosis indicating medical necessity.
A properly executed ABN or the ICD-9 code only permits the laboratory to bill and receive payment. In a post payment audit, the requesting physician may still be asked to show that the tests were medically necessary for a particular patient’s condition. Please ask your Ally Clinical Diagnostics service representative for the current list of LMRP’s (Local Medical Review Policies) and NCD’s (National Coverage Determinations). This will help you to identify when such situations may exist.
85060 Blood smears with written interpretations
85095 – 85109 Bone marrow smears and biopsies
86077 – 86079 Blood Bank Services
88101 – 88130 and Certain Cytopathology services
88160 – 88199
88300 – 88399 Surgical pathology services
86012 and 86013, Certain immunology services
86016 – 86019,
86024 – 86028 and 86034
86068 and 86069, Certain blood bank services
86072 – 86076, 86100 and
86120, 86128 and 86265 – 86267
Medicare continues to reimburse these procedures at 80% of the fee schedule amount and requires that the patient be billed for the remaining 20% coinsurance and any deductible amounts.
In order to comply with the current regulatory requirements, the following information must be provided if Ally Clinical Diagnostics is to bill Medicare directly:
1. Patient’s full name (as it appears on the card)
2. Patient’s address
3. Patient’s sex
4. Medicare HIC#: 9 digits + 1 letter + 1 digit9 digits + 2 letters9 digits + 1 letter
5. Referring physician name/UPIN number
6. Patient’s signature is required if specimen is drawn or collected by an Ally Clinical Diagnostics employee in an Ally Clinical Diagnostics facility
7. Diagnosis code8. As applicable, a signed Advance Beneficiary Notice (ABN) for test/service that is subject to carrier or national medical review policies.
For complete details regarding the Medicare National Coverage Determination Policy, please reference www.cms.gov.
To access the latest ICD-10 information, visit http://www.cms.gov/Medicare/Coding/ICD10/