Pathology/Lab Coding Alert

Question: A physician's office sent a urine specimen to our lab for culture with the diagnosis of low back pain (724.2). Medicare denied the claim as "not medically necessary." What shoud  do?

Iowa Subscriber

Answer: If you don't have any other diagnostic information or a signed advance beneficiary notification (ABN), you can't do much to salvage this claim.

At this point, the only thing you can do is have the physician write a rationale as to why he ordered the culture and appeal the claim accordingly.

Avoid future denials: The best thing you can do with this claim is learn a lesson and take some action to make sure you-re not in this situation again.

Do this: Your lab should become familiar with Medicare's Laboratory National Coverage Determinations (NCDs). These rules provide rationale for medical necessity guidelines and a list of "covered diagnosis" ICD-9 codes. Although the lab can't assign an ordering diagnosis, you can educate clients and even develop a requisition form that allows the ordering physician to select the diagnosis from a list of codes.

Check out urine NCD: A quick look at the lab NCD for bacterial urine culture reveals the problem in your case. ICD-9 code 724.2 (Lumbago, low back pain) is not on Medicare's covered-diagnosis list. But 724.5 (Backache, unspecified) is on the list. An educated physician could take the clinical symptom and select a payable diagnosis.

Resource: You can find the NCDs on the Internet at http://www.cms.hhs.gov/CoverageGenInfo/downloads/manual200810.pdf#1.