Medicare Guidelines National/Local Coverage Determinations

Our goal at Stormont-Vail HealthCare Laboratories is to provide accurate and timely test results to our clinicians in a cost effective manner while continually improving customer services and complying with all federal and state regulations. As the regulatory mandates increase we continually try to find ways to help you continue to provide optimal patient care and remain in regulatory compliance.

The information contained in this notebook is our attempt to provide you with a more user-friendly version of the National and Local Coverage Guidelines for laboratory testing. The Balanced Budget Act of 1997 mandated the development of National Coverage and Administrative Policies for Clinical Diagnostic Laboratory Services via the Negotiated Rulemaking process. For a copy of the complete Medicare document describing the National Coverage Determinations, please go to www.cms.hhs.gov/manuals/pm trans/AB02110.pdf. There is further information regarding the Administrative Policies that resulted from negotiated rulemaking in Program Memorandums AB-02-129 dated September 27, 2002 and AB-02-134 dated October 4, 2002.

This notebook contain lists of ICD-9-CM codes that are covered by Medicare for each test or group of tests. It is important to note that the section in this notebook covering CBC's, Hemograms, WBC, Hemoglobin and Hematocrit, starting on page 4 is set up opposite from all the other National Coverage Determinations. The two ICD-9-CM Code lists starting on page 4 are codes that are not covered by Medicare.

The Negotiated Rulemaking process determined that the date of service must be reported as the date of specimen collection. Medicare states that the person obtaining the specimen must furnish the date of collection for the specimen to the entity billing Medicare. For specimen collections that span more than a 24-hour period, the date of service should be reported as the date the collection began.

CMS Program Memorandum AB-02-030 states the documentation requirements in regards to ordering laboratory services.

• The ordering physician must maintain the ultimate documentation of medical necessity in the beneficiary's medical record.
• The Laboratory must maintain the documentation that it receives from the ordering physician and must ensure that the information listed on the claim accurately reflects the documentation it received from the ordering physician.
• The Laboratory may request additional diagnostic and other medical information from the physician to document that the services it bills are reasonable and necessary. If the Laboratory requests additional documentation, it must request material relevant to the medical necessity of the specific service(s), taking into consideration current rules and regulations on patient confidentiality.

If the patient's diagnoses do not include those covered by Medicare, an Advanced Beneficiary Notice (ABN) must be completed and signed by the patient. An example of this form is contained in this notebook and may be ordered from our Laboratory.

If you review the entire document from CMS regarding the National Coverage Determinations, you will see that we shortened the document by not listing codes that are not covered by Medicare. Again, the exception to this is the guidelines for Blood Counts where the codes listed are those not covered by Medicare. Effective date for National Coverage Determinations is November 25, 2002. It is our hope that this more concise format will help you and your staff deal with this additional Federally mandated administrative requirement, as we work together to provide quality medical laboratory services to your patients.

Diane Burton, MT(ASCP)
Administrative Director of Laboratories

ICD-9 Codes Listed Alphabetically by Description
ICD-9 Codes Listed Numerically

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