# Medicare denials for labs



## jeaner54175@yahoo.com (Jan 6, 2014)

We had two Medicare patients come in for their annual wellness exams and the providers did labs; the labs for the first patient were 80061 with the diagnosis code V70.0 and the second patients labs were 80061 and 85025 with the diagnosis code V70.0. Both patients labs were denied by Medicare because they said they were not medically necessary, any suggestions on what we should have coded?

Thank you,
Lisa Nieft / CPC-A


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## OCD_coder (Jan 6, 2014)

You will need to review the documentation and potentially query the provider to see what risk factors the patient had to indicate the need to perform those lab procedures.   for example if the patient has hyperlipidemia, then that would support the 80061.

Otherwise, the patient should have had an ABN signed prior to the provider seeing them and the patient could be billed.  If no ABN, the clinic will have to absorb the cost.


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## cynthiaarellano14@yahoo.com (Jan 7, 2014)

*supporting dx*

also you may want to print out a list of dx that supports the lab tests in question,  I do know that hypertension does support the lipid panel. but keep in mind that the provider must assign the hypertension dx in order to bill using it. hope this helps CA


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## sddeweese (Jan 8, 2014)

*80061 & 85025*

This link tells you the diagnosis Medicare will accept as supporting medical necessity of the 80061 if it was ordered as a screening due to the Medicare wellness visit. 

http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf

The link below takes you to cms webpage where you can find a list of diagnosis that DO NOT support the medical necessity of 85025:

http://www.cms.gov/Medicare/Coverage/CoverageGenInfo/LabNCDs.html

Scroll down to the download section. Select either the January 2013 zip or pdf file and click to open. Go to the table of contents and click on the title 190.15 - blood counts. This will take you to the section regarding CPT 85025.


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## danachock (Jan 31, 2014)

V70.0 does not qualify for medical necessity with Medicare, you may want to brush up on you NCD and LCDs when you are submitting claims. There are a few applications out there to totally assist you with this. Also you would never use a V70.0 code on a lab - it is only used for routine physical (office visit). Not all physicals require lab draws! 
Thanks
Dana Chock, CPC-A, CCA, CANPC, CHONC
2013/2014 AAPC Chapter President
Anesthesia, Pathology, & Laboratory Coder


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## mitchellde (Feb 1, 2014)

V58.83 with the V58.6- code will support most labs if the patient is on a medication and the reason for the lab is to see if the medication is being effective and is not adversely affecting other organs or systems.


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## dovekrn (Apr 9, 2014)

*screening labs*

Medicare pays for screening lipid once every five years.  Use dx screening code for lipid is V81.0.  CBC's are not covered ever under screening codes ever, must have sick dx for that.  Use V70.0 is for examination portion, not labs.  IF you need to run lipid due to pt having hyperlipidemia, then use 272.4 not screening dx, not covered under wellness but covered under medicare as usual,just not at 100 %.  This can be done more than every five years.


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