Corporate

March 18, 2014

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

Claims for the following CPT codes are often denied as "not medically necessary" (remark code CO-50).

  • 84443: thyroid stimulating hormone
  • 83036: glycosylated hemoglobin
  • 85025: complete blood count

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-9 codes that fall into 3 categories:

  • Covered ICD-9 codes
  • Non-covered ICD-9 codes
  • Codes that do not support medical necessity

Before Submitting Claims

  • Refer to the ICD-9 code lists for the applicable NCD.
    • Download the ICD-9 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 CPT Codes Included
190.25 Alpha-fetoprotein 82105
190.15 Blood Counts 85004
85007
85008
85013
85014
85018
85025
85027
85032
85048
85049
190.20 Blood Glucose Testing NCD 190.20A:
82948
82962
NCD 190.20B:
82947
190.26 Carcinoembryonic Antigen 82378
190.19 Collagen Crosslinks, Any Method 82523
190.24 Digoxin Therapeutic Drug Assay 80162
190.34 Fecal Occult Blood Test 82272
190.32 Gamma Glutamyl Transferase 82977
190.21 Glycated Hemoglobin/Glycated Protein 82985
83036
190.33 Hepatitis Panel/Acute Hepatitis Panel 80074
190.27 Human Chorionic Gonadotropin 84702
190.14 Human Immunodeficiency Virus (HIV) Testing (Diagnosis) 86689
86701
86702
86703
87390
87391
87534
87535
87537
87538
190.13 Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) 87536
87539
190.23 Lipid Testing NCD 190.23A:
83700
83701
83704
NCD 190.23B:
80061
82465
83718
84478
190.16 Partial Thromboplastin Time (PTT) 85730
190.31 Prostate Specific Antigen 84153
190.17 Prothrombin Time (PT) 85610
190.18 Serum Iron Studies 82728
83540
83550
84466
190.22 Thyroid Testing 84436
84439
84443
84479
190.28 Tumor Antigen by Immunoassay (CA 125) 86304
190.29 Tumor Antigen by Immunoassay (CA 15-3/CA 27.29) 86300
190.30 Tumor Antigen by Immunoassay (CA 19-9) 86301
190.12 Urine Culture, Bacterial 87086
87088

Reference:


Two Vantage Way, Nashville, TN 37228 © CGS Administrators, LLC. All Rights Reserved