MEDICAL NECESSITY

Medicare is required by federal law to pay only for services it considers medically necessary to diagnose or treat an illness or injury or to improve the function of a malformed body member. As a result, Medicare often requires a specific diagnosis for certain laboratory tests before they will consider a test medically necessary.

Although physicians may order any tests they believe to be necessary to diagnose and treat a patient appropriately, Medicare will only pay for those that meet the Medicare definition of medical necessity.

Therefore, all Medicare claims submitted by UPHS – Marquette must include complete medical necessity documentation using the ICD-9CM coding system to be compliant and eligible for reimbursement of services provided.

ROUTINE SCREENING TESTS:

Routine screening test(s) are not a Medicare covered service unless specified in Medicare law. The patient is financially responsible for payment of routine screening tests outside of the guidelines.

MEDICARE COVERED SCREENING TESTS (Be sure to order correct screening Test)
  • SPSA Prostate Specific Antigen Screening (1/year) -G0103
  • SFOB Fecal Occult Blood Screening (1/year) -G0107
  • PAP SMEAR (1/ every 2 years) -G0145
Points to Remember:
  • An ABN must be submitted with every lab requisition when national or local coverage tests are ordered and there is not appropriate ICD-9 diagnostic information (narrative or numeric) provided that supports the medical necessity of the test or there are frequency limitations to the tests.
  • The ICD-9 diagnostic information and narrative must be consistent with the documentation in the patient's chart.
  • The ICD-9 diagnostic information and narrative must be clinically relevant for the test ordered and coded to the highest degree of specificity.
  • An ABN must be signed before a specimen is drawn or service is provided.

SCREENING FOR MEDICAL NECESSITY

Laboratory testing is deemed Medically Necessary by Medicare if the test is "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."

Any other use of laboratory testing is considered screening. Screening does not always denote that the ordered test is unnecessary or deemed to be poor medical practice. Screening tests cannot be directly linked to an established diagnosis, sign, or symptom.

In order to establish Medical Necessity, the test order must be accompanied by the appropriate diagnostic information justifying the test order. This information should be submitted in the form of an ICD-9 code. Laboratory requisitions have incorporated the commonly used ICD-9 codes for each practice area. Feel free to include additional Diagnoses/ICD-9 if those listed do not reflect the patient's signs/symptoms/diagnosis accurately.

The following tests have frequency limitations for Medicare Beneficiaries please see the CMS Manual for further information (link):

  • Urine Culture (87088, 87086) 1 every encounter
  • HIV Diagnostic Testing . 1 every 3 to 6 months
  • Prothrombin Time (85610) 1 every 2 to 3 weeks
  • Collagen Cross Links based on therapy
  • Blood Glucose , 4 every 12 months
  • Glycated Hemoglobin (83036) 1 every 3 months, except 1 per month during pregnancy
  • Thyroid Stimulating Hormone (84443) 2 every 12 months
  • Lipid Panel (80061, 82465, 83718) 1 every 4 months
  • Digoxin Therapeutic Drug Assay (80162) 1 every 12 months
  • Carcinoembryonic antigen (82105) Varies based on diagnosis
  • Human Chorionic Gonadotropin (84702) 1 every month for diabetics or as needed.
  • Immunoassay for tumor antigen, quant CA125- based on therapy
  • Prostate Cancer Screening Test (G0103) 1 every 12 months s
  • Glutamyltransferase (82977)
  • Acute Hepatitis Panel (80074) Varies based on diagnosis
  • Screening Fecal Occult Blood (G0107) 1 every 12 months
  • Screening Pap Smear (G0123, P3000, P3001) 1 every 2 years

Local Coverage Determinations (LCD) have also been developed for a limited number of tests (i.e. Flow Cytometry, Reticulocyte Count) in a regional coverage area. The NCD or LCD includes covered diagnoses for each test.

However, there are instances where a practitioner may want to monitor a certain lab test due to a particular treatment protocol (e.g., a medication a patient is taking may affect thyroid function so the practitioner monitors the TSH on the patient). If the patient's signs/symptoms/diagnoses are not among the diagnoses listed in the appropriate NCD, an ABN must be completed.