Medicare Guidelines

Medical Necessity / Diagnosis Codes

Every third party bill must have a valid diagnosis code (ICD-10 Code).

The appropriate diagnosis or diagnosis code must be written on the laboratory requisition for the patient’s condition on the specified date of service.

Medical Necessity is defined by the Medicare Part B Carrier as those tests and services that it determines to be “reasonable and necessary”. The Part B Carrier may develop “local coverage determinations” (LCDs) for specific tests. The Medicare National Coverage Determinations (NCDs) for laboratory tests are similar to the local LCDs. The NCD and the LCD indicates which diagnoses, signs, or symptoms are payable for these specific tests.

If a test is ordered in which a local medical review policy or a national coverage decision exists, there must be appropriate diagnosis codes for that test; otherwise, Medicare will deny payment.

When ordering a test that does not meet a local medical review policy or a national coverage decision, an Advanced Beneficiary Notice (ABN) must be signed by the patient and submitted to us. The purpose of the ABN is to give the patient advance notice that Medicare may not pay for the test ordered.

Tests Covered by the National Coverage Determinations (NCD)

    • Alpha fetoprotein (AFP)
    • Blood Counts (CBC)
    • CA 15-3
    • CA 19-9
    • CA 27.29
    • CA-125
    • CEA
    • Collagen Crosslinks (N-Telopeptide)
    • Culture, Urine
    • Digoxin
    • GGT
    • Glucose Testing
    • HCG, Quantitative
    • Hemoglobin A1C
    • Hepatitis Panel, Acute
    • HIV Testing, Diagnosis
    • HIV Prognosis, including Monitoring
    • Iron Studies: Ferritin, Iron,IBC,Transferrin
    • Lipid Testing (Lipid Profile, including Cholesterol)
    • Occult Blood
    • PSA
    • PT
    • PTT
    • Thyroid Testing: T4, Free T4, TSH, Thyroid Hormone (T3 or T4) Uptake or THBR

Tests Covered by the Local Coverage Determinations (LCD):

  • Allergy (Rast Test)
  • B-Type Natriuretic Peptide (BNP)
  • Drug Screening
  • Heavy Metal Screening
  • Molecular Pathology Procedures
  • Vitamin D, 25 OH

Medicare Preventative Services

Please visit this Centers for Medicare & Medicaid Services page to select your service, to review for frequency, LCD and NCD.

Medicare compliance, documentation for lab services:

See Provider Compliance Services Fact Sheet PDF

Medicare NCCI Procedure to Procedure (PTP) Edits

Screening Pap Smears:

Medicare covers one screening Pap smear every two years, and more if the beneficiary falls into one of the following categories:

Patient is of childbearing age and has had an exam indicating the presence of cervical or vaginal cancer or other abnormality during any of the preceding three years;

  • Patient is considered to be at high risk for vaginal cancer as evidenced by prenatal exposure to diethylstilbestrol or for cervical cancer as evidenced by any of the following:
    • Early onset of sexual activity (under 16 years of age)
    • Multiple sexual partners (five or more in a lifetime)
    • History of a sexually transmitted disease (including HIV)
    • Fewer than three negative, or no Pap smears within the previous seven years

Screening Fecal Occult Blood Tests:

Medicare covers fecal occult blood tests on asymptomatic patients once every 12 months for individuals who have attained age 50.

Screening Prostate Specific Antigen (PSA):

Medicare covers a screening PSA once every 12 months for male individuals who have attained age 50.

Cardiovascular Screening Tests:

Cardiovascular Screening Tests (cholesterol, HDL, Triglycerides) – is covered once every five years.

Diabetes Screening Tests:

Diabetes Screening Tests (Glucose, 2Hr PP) – covers: a) Two screening tests per calendar year for individuals diagnosed with pre-diabetes; b) One screening test per year for individuals previously tested who were not diagnosed with pre-diabetes, or who have never been tested.

Hepatitis C Screening Tests:

Medicare will cover Hepatitis screening tests on patients at high risk for HCV infection and will cover one for patients who do not meet the high risk definition but who were born from 1945 through 1965.

HIV Screening Tests:

Medicare covers one annual HIV screening test for patients that are at increased risk for HIV infection and three voluntary HIV screening tests on pregnant Medicare patients.

No Appointment Necessary
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