National Coverage Determinations (NCD's) is a document for diagnostic laboratory testing stating The Centers for Medicare and Medicaid (CMS) policies with respect to circumstances under which laboratory test(s) will be considered reasonable and necessary, and not screening, for Medicare purposes. Regional Pathology Services accepts Medicare assignment and is not allowed to bill Medicare beneficiaries for the NCD tests listed below unless an ABN is executed by the provider that tells the beneficiary in advance of the service that they will be responsible for the payment of the test(s) if Medicare should deny payment.·
ABN’s should be executed when:
- Tests(s) are deemed by the NCD policy as not medically necessary.
- Screening test(s) that are part of a routine examination where the patient shows no signs nor symptoms of disease.
- Test(s) that exceed the NCC frequency limits.
- Test(s) that are considered experimental or investigational/not approved by FDA.
These policies are updated every three months, with revisions published between final publications. It is ideal to use the latest version of the NCD policies.
It is the policy of Regional Pathology Services and The Nebraska Medical Center to ensure that an appropriate Advanced Beneficiary Notice (ABN) is obtained from Medicare beneficiaries for laboratory tests prior to collection of the specimen(s) that are deemed to be not reasonable and necessary.
Effective January 1, 2005 all laboratory test(s) requests for Medicare patients that does not have a diagnosis that meets the NCD guidelines for medical necessity and do not have an ABN attached, will be billed directly to the clinic/office that initiates the test order. Testing that does not require an ABN will be billed to Medicare. Blanket or routine ABN forms are nt allowed by CMS. ABNs should be executed when non-payment is anticipated.
ABN Usage Overview
- Obtain ABN if tests(s) may or does not meet medical necessity requirements.
- Obtain ABN if test(s) may only be paid for a limited number of times (frequency limits).
- Obtain ABN if test(s) used only on investigational purposes.
- Patient request services that are not deemed medically reasonable by the provider.
- Use form CMS-R-131.
- Fill in patient's last, first name, and middle initial if applicable.
- List test(s) in the space provided.
- Mark the applicable reason Medicare may not pay.
- Fill in the estimated cost of the (test)s to the beneficiary.
- "X" Option 1 or Option 2 or Option 3.
- Date form.
- Have beneficiary sign.
- Attach original to the laboratory request form (requisition).
- Retain the a copy for your records and give a copy to the beneficiary.
- Note that the NCD for Blood Counts that includes a Complete Blood Count and all of the applicable components is an exclusionary policy, meaning it does not list the covered codes, only those expected to be denied.
The following tests for Medicare Coverage Determinations (NCD) Coding Policies:
NCDs
Alpha-fetoprotein (AFP)
82105
Blood Counts
85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027
(Notice Blood Counts is an exclusionary policy for ICD-9 codes listed)
Blood Glucose Testing
82947,82948,82962
Carcinoembryonic Antigen (CEA)
82378
Collagen Crosslinks, any Method
82523
Digoxin Therapeutic Drug Assay
80162
Fecal Occult Blood Test (FOBT)
82270
Gamma Glutamyl Transferase (GGT)
82977
Glycated Hemoglobin/Glycated Protein
82985,83036
Hepatitis Panel/Acute Hepatitis Panel
87340,86803,86705,86709
Human Chorionic Gonadotropin (hCG)
84702
Human Immunodeficiency Virus (HIV) Testing (Diagnosis)
86689, 86701, 86702, 86703, 87390, 87391, 87534, 87535, 87537, 87538
Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring)
87536, 87539
Lipid Testing
80061, 82465, 83715, 83716, 83718, 83721, 84478
Partial ThromboplastinTime (PTT)
85730
Prostate Specific Antigen (PSA)
84153
Prothrombin Time (PT)
85610
Iron Studies
82728, 83540, 83550, 84466
Thyroid Testing
84436,84439,84443,84479
Tumor Antigen by Immunoassay - CA 125
86304
Tumor Antigen by Immunoassay - CA 15-3/CA 27.29
86300
Tumor Antigen by Immunoassay - CA 19-9
86301
Urine Culture, Bacterial
87086, 87088, 87184, 87186
Local Coverage Determinations (LCD’s) refers to the same types of exclusions as the NCD policies. Medical fiscal intermediaries or carriers have such exclusions in their policies. In addition to the NCD policies the Medicare billing contractor for Regional Pathology Services has enacted the following LCD policies.
LCD Policies
- B-type Natriuretic Peptide
- Cytogenetic Studies
- Flow Cytometry
- Free Prostate Specific Antigen (Free PSA)
- Helicobacter Pylori Testing
- Prostate Specific Antigen (PSA)
Search the Center for Medicare and Medicaid web site.
