Pathology/Lab Coding Alert

Question: How can I find information about Medicare coverage for lab and pathology procedures in terms of procedure coding, covered diagnoses, testing frequency, etc.?

Mississippi Subscriber

Answer: Medicare provides National Coverage Determinations (NCDs) for national rules, and many Medicare Administrative Contractors (MACs) provide their regional rules in the form of Local Coverage Determinations (LCDs).

1-stop shopping: The quickest way to find coverage rules that apply to your lab is to turn to the Medicare coverage database search tool. At this site, you can enter a code or keyword and perform a search for NCDs and LCDs that apply in your locale.

NCDs: Medicare enumerates NCDs in Publication 100-3. You’ll find the extensive pathology and laboratory NCDs in Section 190 of the manual (currently linked in Chapter 1 Coverage Determinations Part 3, Sections 170-190.34).

NCDs are national policies developed and released by the Centers for Medicare & Medicaid Services (CMS) that establish Medicare coverage for specific medical items or services across all states. MACs are required to follow NCDs, and NCDs trump LCDs. You shouldn’t expect any difference in determinations between jurisdictions, because the coverage is national.

LCDs: The most up-to-date resource for LCDs that affect your lab is your MAC. An LCD outlines how your contractor will review claims, based partly on procedure and diagnosis coding, to determine whether a particular service is reasonable and necessary, and therefore covered in your MAC’s jurisdiction. 

Development: NCDs and LCDs aren’t static. Revisions, additions, and deletions occur over time. Medicare might approve new tests through the NCD process, which takes nine to 12 months. MACs’ LCD processes may take less time. Changes to NCDs and LCDs occur through a process that invites your participation through posting of proposals and soliciting comments before establishing the final coverage determination.

Ellen Garver, BS, BA