Pathology/Lab Coding Alert
CMS Adds 401.1 to Lipid NCD Medical-Necessity List
Question: Physicians often order lipid testing for patients diagnosed with benign hypertension because they may have an increased risk of heart disease, but we've received Medicare denials for the tests as "not medically necessary." Why is this, and what can we do to get paid for these tests, such as a lipid panel (80061)? Illinois Subscriber Answer: The bad news is that you're right: Labs have received denials for lipid tests ordered with a benign hypertension diagnosis since Medicare instituted the National Coverage Determination (NCD) for lipid testing. The good news is that Medicare recently announced its intention to modify the NCD to correct the situation. Medicare will add the phrase "any disease leading to the formation of atherosclerotic disease" - which includes all forms of hypertension - to its list of coverage indications. The agency will also add 401.1 (Essential hypertension; benign) to the list of covered ICD-9 codes. CMS says that benign essential hypertension is a common precursor to atherosclerotic disease in its National Coverage Analysis #CAG-00188N. You can view the coverage analysis at http://www.cms.gov/ncdr/memo.asp?id=94. The lipid NCD impacts coverage for the following CPT codes: - Reader Questions and You Be the Coder were prepared with the assistance of Laurie Castillo, MA, CPC, CPC-H, CCS-P, president of Professional Coding and Compliance Consulting in Manassas, Va.
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CMS Adds 401.1 to Lipid NCD Medical-Necessity List
Question: Physicians often order lipid testing for patients diagnosed with benign hypertension because they may [...]
