Pathology/Lab Coding Alert

Question: How should we use the -Covered ICD-9 Codes- list in the National Coverage Determinations for laboratory tests?

Minnesota Subscriber

Answer: Medicare has 23 National Coverage Determinations (NCDs) for laboratory tests ranging from alpha-fetoprotein to prostate specific antigen. For each NCD, Medicare will pay for the test only if you can show medical necessity. That means the ordering physician must indicate the reason for the test -- and Medicare must have the information in the form of an ICD-9 code. That's called the -ordering diagnosis.-

Each NCD includes a list of -covered ICD-9 codes- for the tests. You can know in advance if Medicare will cover the test by looking at the list to see if the ordering diagnosis is one of the covered codes.

Caution: You must use the ordering diagnosis assigned by the physician requesting the test, even if it is not on the covered list. You should never assign an ICD-9 code from the list just to get paid for a test -- that is considered fraudulent.

Medicare updates the NCDs quarterly, including adding or deleting ICD-9 codes based on code changes or new information about medical conditions that indicate medical necessity for a given test.

For instance, as of Jan. 1, Medicare added the following codes as payable diagnoses under the listed NCDs:

- Prothrombin time -- V58.83 (Encounter for therapeutic drug monitoring)

- Partial thromboplastin time -- V58.83

- Thyroid testing -- 783.0 (Anorexia), 793.99 (Other nonspecific abnormal findings on radiological and other exams of body structure)

- Fecal occult blood test -- 995.20 (Unspecified adverse effect of unspecified drug, medicinal and biological substance).

The most recent version of the NCDs is at www.cms.hhs.gov/CoverageGenInfo/downloads/manual200701.pdf#17 

Reader Questions and You Be the Coder were prepared with the assistance of R.M. Stainton Jr., MD, president of Doctors- Anatomic Pathology Services in Jonesboro, Ark.