Pathology/Lab Coding Alert

Clear Up National Coverage Confusion for Clinical Labs

Published on Sun Dec 01, 2002

While the implementation of Medicare's 23 National Coverage Decisions (NCDs) has brought confusion to many labs, you can gain some clarity here.

Medicare's edit software missed the Nov. 25 deadline (see "Labs May Wait for NCD Claims" in the September 2002 Pathology/Lab Coding Alert ), and carriers' instructions to labs have been mixed.

"We were told in September by our carrier to download a 234-page document and inform our clients of the changes by Nov. 25," says Stan Werner, MT (ASCP), administrative director of Peterson Clinical Laboratory in Manhattan, Kan. Others received little direction aside from their carriers removing long-standing local medical review policies (LMRPs) for certain lab tests.

The NCDs impact diagnosis and CPT coding for more than 60 lab tests (see "Clinical Laboratory National Coverage Decisions" p. 94), representing about 60 percent of lab claims, CMS says. That's why you need to know the answers to the following commonly asked questions:

Q: Two dates are circulating in the lab community for the NCDs: Nov. 25, 2002, and Jan. 1, 2003. When are the NCDs effective, and why do we hear these two different dates?

A: The NCDs are effective for services provided on or after Nov 25. However, Medicare's edit software, which allows carriers and fiscal intermediaries (FIs) to process claims under the new rules, won't be in place until Jan. 1, 2003. Starting Nov. 25, you should submit claims in accordance with the NCDs because carriers and FIs can go back and review these claims and make adjustments once the edit software is available in January.

Q: Some Medicare carriers have removed from their Web sites LMRPs for procedures such as complete blood count (CBC). How do we know which ICD-9 codes support medical necessity for a procedure if the LMRP is gone?

A: Medicare instructed carriers to remove LMRPs that conflict with NCDs by Nov. 25. Even though carriers cannot review claims under the new rules until the edit software is available, removal of conflicting LMRPs should eliminate erroneous edits and denials. You can find the ICD-9 codes that support medical necessity in the NCD from your carrier or CMS Program Memorandum AB-02-110 available at http://www.cms.gov/manuals/pm_trans/AB02110.pdf. Remember, CBC is an "exclusionary" NCD, meaning it does not list the covered codes, only those expected to be denied (see next question).

Q: In addition to a list of "ICD-9-CM Codes Covered by Medicare Program," each NCD also lists diagnosis codes under the headings "ICD-9-CM Codes Denied" and "ICD-9-CM Codes That Do Not Support Medical Necessity." What is the difference between the latter two lists, and how should we report codes from them?

A: Each NCD accounts for every ICD-9 code in one of the three categories mentioned. Two of the categories list specific code numbers, while the third list is a "default" category including "any ICD-9-CM code not listed in either of the [other two] sections."

Medicare will not pay for services performed with an ICD-9 from the "codes denied" list. Services ordered with these codes are generally statutorily noncovered, so you may bill the beneficiary directly. However, if you bill Medicare first, use modifier -GY (Item or service statutorily excluded or does not meet the definition of any Medicare benefit) to indicate that you are billing noncovered services to receive a formal denial.

The other noncovered list is for codes that generally do not support medical necessity. Medicare may pay claims with an ICD-9 code from this list if you provide documentation that supports medical necessity in the particular situation. The carrier cannot summarily deny codes from this list without reviewing the documentation. Each carrier will provide direction to labs about how to "flag" a claim that includes documentation. Some carriers ask labs to submit only hard copy if a claim includes documentation. Others instruct labs to use an electronic indicator to alert the carrier of documentation. For example, one carrier instructs labs to use modifier -22 (Unusual procedural services) on CMS Form 1500 to indicate the presence of documentation.

Q: Under what circumstances should we use modifiers -GZ, -GA and -GY with codes from the "denied" or "not medically necessary" ICD-9 lists?

A: Use these three -G modifiers when you don't expect Medicare to cover the service for a given diagnosis, according to Program Memorandum AB-02-134. If the item is not covered for reasons other than medical necessity, such as most items on the NCD "denied" list, (for example, screening tests), use modifier -GY. Report modifiers -GA (Waiver of liability statement on file) or -GZ (Item or service expected to be denied as not reasonable and necessary) when you expect Medicare to deny the claim based on medical necessity, such as most items on the NCD "not medically necessary" list. The difference in these two modifiers is whether you have a signed advance beneficiary notice (ABN) on file, with -GA meaning that you do and -GZ meaning that you don't.

Q: The NCDs published in the final rule (Nov. 23, 2001, Federal Register) include some codes that are no longer current. Will these be updated to incorporate annual CPT and ICD-9 code changes?

A: Yes, CMS provides clerical maintenance of the coding lists, revising the NCDs to be consistent with annual CPT and ICD-9 updates. For example, to accommodate CPT 2001 revisions, the urine culture NCD published in Program Memorandum AB-02-110 includes a CPT code list that has been updated from the Federal Register version. Your carriers should provide updates.

Answers were prepared with the assistance of Christopher Young, president of Laboratory Management Support Services in Phoenix.

Clinical Laboratory National Coverage Decisions

Use this list as a quick reference to lab tests covered by the NCDs

* Note: This table uses abbreviated descriptors rather than complete CPT code definitions.

Bacterial Urine Culture
87086 Colony count
87088 Presumptive identification
87184, 87186 Susceptibility studies

Human Immunodeficiency Virus (2 NCDs)
87534-87539 HIV-1, HIV-2 infectious agent detection by nucleic acid
87390, 87391 HIV-1, HIV-2 infectious agent antigen detection by enzyme immunoassay
86689, 86701-86703 Antibody, HTLV or HIV-1, HIV-2

Blood Counts
85007 Manual differential WBC
85008 Smear without differential
85013, 85014 Hematocrit
85018 Hemoglobin
85021 Automated hemogram
85022, 85031 Hemogram and differential
85023-85025 Hemogram, platelet count and differential WBC
85027 Hemogram and platelet count
85048 White blood cells
85590, 85595 Platelet count