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March 18, 2014

Laboratory Services: Medical Necessity and National Coverage Determinations (NCDs)

The Centers for Medicare & Medicaid Services (CMS) created 23 National Coverage Determinations (NCDs) for specific clinical laboratory tests, including the tests listed above. Whereas most NCDs describe covered indications and limitations in narrative form, laboratory NCDs list specific ICD-10 codes that fall into 3 categories:

  • Covered ICD-10 codes
  • Non-covered ICD-10 codes
  • Codes that do not support medical necessity

Before Submitting Claims

  • Refer to the ICD-10 code lists for the applicable NCD.
    • Download the ICD-10 code lists for each NCD from the CMS websiteExternal Website: under Downloads, select Lab Code List.
  • If the patient's condition is on the non-covered list or list of codes that do not support medical necessity, you may consider asking the patient to sign an Advance Beneficiary Notice of Noncoverage (ABN).
    • Refer to the CGS Modifier Tool, HCPCS modifier GA, for more information, and to the CMS resources in the Reference section of this article for further guidance on issuing these notices.
  • Remember to double-check medical records to ensure that valid orders and signatures are present.
Current list of Lab NCDs: Alphabetical
NCD# Title
190.25 Alpha-fetoprotein
190.15 Blood Counts
190.20 Blood Glucose Testing
190.26 Carcinoembryonic Antigen
190.19 Collagen Crosslinks, Any Method
190.24 Digoxin Therapeutic Drug Assay
190.34 Fecal Occult Blood Test
190.32 Gamma Glutamyl Transferase
190.21 Glycated Hemoglobin/Glycated Protein
190.33 Hepatitis Panel/Acute Hepatitis Panel
190.27 Human Chorionic Gonadotropin
190.14 Human Immunodeficiency Virus (HIV) Testing (Diagnosis)
190.13 Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring)
190.23 Lipid Testing
190.16 Partial Thromboplastin Time (PTT)
190.31 Prostate Specific Antigen
190.17 Prothrombin Time (PT)
190.18 Serum Iron Studies
190.22 Thyroid Testing
190.28 Tumor Antigen by Immunoassay (CA 125)
190.29 Tumor Antigen by Immunoassay (CA 15-3/CA 27.29)
190.30 Tumor Antigen by Immunoassay (CA 19-9)
190.12 Urine Culture, Bacterial

Reference:

Reviewed: 12.15.22

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