Laboratory National Coverage Determination (NCD) Edit Software Changes: October 2009
MLN Matters® Number: MM6548
Related Change Request (CR) #: 6548
Related CR Release Date: July 10, 2009
Effective Date: October 1, 2009
Related CR Transmittal #: R1766CP
Implementation Date: October 5, 2009
Provider Types Affected
Physicians, providers, and suppliers submitting claims to Palmetto GBA for clinical diagnostic laboratory services provided for Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 6548 which announces the changes that will be included in the October 2009 release of Medicare’s edit module for clinical diagnostic laboratory National Coverage Determinations (NCDs). The last quarterly release of the edit module was issued in July 2009. Be sure billing staff is aware of the changes.
Background
The NCDs for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published in a final rule on November 23, 2001.
Nationally uniform software was developed and incorporated in Medicare’s systems so that laboratory claims subject to one of the 23 NCDs were processed uniformly throughout the nation effective January 1, 2003.
In accordance with the Medicare Claims Processing Manual, Chapter 16, Section 120.2 (see www.cms.hhs.gov/manuals/downloads/clm104c16.pdf (PDF, 441 KB), the laboratory edit module is updated quarterly (as necessary) to reflect ministerial coding updates and substantive changes to the NCDs developed through the NCD process.
CR 6548 announces changes to the laboratory edit module for changes in laboratory NCD code lists for October 2009. These changes become effective for services furnished on or after October 1, 2009. The changes that are effective for dates of service on and after October 1, 2009 are as follows:
For the Urine Culture, Bacterial:
- Add ICD-9-CM codes 670.10, 670.12, 670.14, 670.20, 670.22, 670.24, 670.30, 670.32, 670.34, 670.80, 670.82, 670.84, and 789.7 to the list of ICD-9-CM codes that are covered by Medicare for the Urine Culture, Bacterial (190.12) NCD
For Blood Counts:
- Add ICD-9-CM codes V26.42, V26.82, V53.50-V53.51, V53.59, V61.07-V61.08, V61.23-V61.25, V61.42, V72.60-V72.63, and V72.69 to the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD
- Delete ICD-9-CM codes V53.5 and V72.6 from that list
For Partial Thromboplastin Time (PTT):
- Add ICD-9-CM codes 453.50-453.52, 453.6, 453.71-453.77, 453.79, 453.81-453.87, 453.89, 789.7, and 995.24 to the list of ICD-9-CM codes that are covered by Medicare for the PTT (190.16) NCD
- Delete ICD-9-CM code 453.8 from that list
For Prothrombin Time (PT):
- Add ICD-9-CM codes 209.70-209.75, 209.79, 453.50-453.52, 453.6, 453.71-453.77, 453.79, 453.81-453.87, 453.89, 789.7, and 995.24 to the list of ICD-9-CM codes that are covered by Medicare for the PT (190.17) NCD
- Delete ICD-9-CM code 453.8 from that list
- Replace the duplicate ICD-9-CM code 868.19 with 868.09 within that list
For Serum Iron Studies:
- Add ICD-9-CM codes 209.31-209.36, 209.70-209.75, 209.79, 239.81, 239.89, 285.3, 453.50-453.52 and 569.87 to the list of ICD-9-CM codes that are covered by Medicare for the Serum Iron Studies (190.18) NCD
- Delete ICD-9-CM code 239.8 from the list of ICD-9-CM codes that are covered by Medicare for the Serum Iron Studies (190.18) NCD
For Thyroid Testing:
- Add ICD-9-CM codes 279.41, 279.49, 784.42-784.44, 784.51, 784.59, 799.21-799.25, 799.29, and V10.91 to the list of ICD-9-CM codes that are covered by Medicare for the Thyroid Testing (190.22) NCD
- Delete ICD-9-CM codes 279.4, 784.5, and 799.2 from that list
For Lipids Testing:
- Add ICD-9-CM codes 438.13-438.14 to the list of ICD-9-CM codes that are covered by Medicare for the Lipids Testing (190.23) NCD
For Digoxin Therapeutic Drug Assay:
- Add ICD-9-CM codes 787.04, 799.21-799.25, 799.29 and 995.24 to the list of ICD-9-CM codes that are covered by Medicare for the Digoxin Therapeutic Drug Assay (190.24) NCD
- Delete ICD-9-CM code 799.2 from that list
For Alphafetoprotein:
- Add ICD-9-CM codes 209.70-209.75 and 209.79 to the list of ICD-9-CM codes that are covered by Medicare for the Alpha-fetoprotein (190.25) NCD
For Carcinoembryonic Antigen:
- Add ICD-9-CM codes 209.70-209.75 and 209.79 to the list of ICD-9-CM codes that are covered by Medicare for the Carcinoembryonic Antigen (190.26) NCD
For Gamma Glutamyl Transferase:
- Add ICD-9-CM codes 209.70-209.75, 209.79, 453.6, 453.71-453.77, 453.79, 453.81-453.87, 453.89, 569.87, 969.00-969.05, 969.09, 969.70-969.73 and 969.79 to the list of ICD-9-CM codes that are covered by Medicare for the Gamma Glutamyl Transferase (190.32) NCD
- Delete ICD-9-CM codes 453.8, 969.0 and 969.7 from that list
For the Hepatitis Panel/Acute Hepatitis Panel:
- Add ICD-9-CM codes 787.04 and 789.7 to the list of ICD-9-CM codes that are covered by Medicare for the Hepatitis Panel/Acute Hepatitis Panel (190.33) NCD
For Fecal Occult Blood Test:
- Add ICD-9-CM codes 209.70-209.75, 209.79, 285.3, 569.87, 787.04, 789.7 and 995.24 to the list of ICD-9-CM codes that are covered by Medicare for the Fecal Occult Blood Test (190.34) NCD
- Delete CPT® code G0394 from the list of CPT® codes covered by Medicare for the Fecal Occult Blood Test (190.34) NCD
For all 23 Lab NCDs:
- ICD-9-CM codes V20.31-V20.32, V60.81. V60.89, V80.01, and V80.09 will be denied for all 23 NCDs
- ICD-9-CM codes V60.8 and V80.0 will be deleted from the non-covered by Medicare lists for all 23 NCDs
Additional Information
The official instruction (CR 6548) issued to Palmetto GBA may be found at
If you have questions, please contact our Provider Contact Center at our toll-free number (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092) South Carolina).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2008 American Medical Association.