MLN Matters Number: MM6213 Revised
RRelated Change Request (CR) #: 6213
Related CR Release Date: October 2, 2008
Effective Date: October 1, 2008
Related CR Transmittal #: R1606CP
Implementation Date: October 6, 2008
Note: This article was revised on October 21, 2008, to correct the reference to the NCD from 190.18 to 190.19 on the bottom of page 3. A code for Gamma Glutamyl Transferase was corrected to 571.42 on page 5. It also corrected two codes on page 6 for FOBT, by adding a zero to correct the ICD-9-CM codes to 209.40 and 209.50. All other information remains the same.
Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare carriers, fiscal intermediaries (FIs), or Part A/B Medicare Administrative Contractors (A/B MACs) for clinical diagnostic laboratory services provided for Medicare beneficiaries.
What You Need to Know
This article is based on Change Request (CR) 6213 which announces the changes that will be included in the October 2008 release of the edit module for clinical diagnostic laboratory National Coverage Determinations (NCDs). The last quarterly release of the edit module was issued in July 2008. CR 6213 incorporates all changes from July 2008 to the present.
Background
The National Coverage Determination (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 the shared 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 (Publication 100-04), Chapter 16, Section 120.2 (see http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf), 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 6213 announces changes to the laboratory edit module, for changes in laboratory NCD code lists for October 2008 as described below. These changes become effective for services furnished on or after October 1, 2008.
For Bacterial Urine Culture:
- Add ICD-9-CM codes 038.12, 599.70, 599.71, 599.72, 780.60, 780.61, 780.62, 780.63, 780.64, 780.65, 788.91, and 788.99 to the list of ICD-9-CM codes covered by Medicare for the Urine Culture, Bacterial (190.12) NCD.
- Delete ICD-9-CM codes 599.7, 780.6, and 788.9 from the list of ICD-9-CM codes covered by Medicare for the Urine Culture, Bacterial (190.12) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Urine Culture, Bacterial (190.12) NCD.
For HIV Testing:
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the HIV Testing (Prognosis Including Monitoring (190.13)) NCD.
- Add ICD-9-CM codes 078.12, 136.21, 136.29, 780.60, 780.61, 780.62, 780.63, 780.64, and 780.65 to the list of ICD-9-CM codes covered by Medicare for the HIV Testing (Diagnosis) (190.14) NCD.
- Delete ICD-9-CM codes 136.2 and 780.6 from the list of ICD-9-CM codes covered by Medicare for the HIV Testing (Diagnosis) (190.14) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the HIV Testing (Diagnosis) (190.14) NCD.
For Blood Counts:
- Add ICD-9-CM codes 078.12, V45.11, V45.12, V49.83, V51.0, V51.8, V61.01, V61.02, V61.03, V61.04, V61.05, V61.06, V61.09, V62.21, V62.22, V62.29 and V72.42 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 V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Blood Counts (190.15) NCD.
- Delete ICD-9-CM codes V45.1, V51, V61.0, and V62.2 from the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD.
For Partial Thromboplastin Time (PTT):
- Add ICD-9-CM codes 275.5, 238.77, 571.42, 599.70, 599.71, 599.72, and 611.89 to the list of ICD-9-CM codes covered by Medicare for the Partial Thromboplastin Time (PTT) (190.16) NCD.
- Delete ICD-9-CM codes 599.7 and 611.8 from the list of ICD-9-CM codes covered by Medicare for the Partial Thromboplastin Time (PTT) (190.16) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Partial Thromboplastin Time (PTT) (190.16) NCD.
For Prothrombin Time (PT):
- Add ICD-9-CM codes 209.20, 209.21, 209.22, 209.23, 209.24, 209.25, 209.26, 209.27, 209.29, 238.77, 511.81, 511.89, 571.42, 599.70, 599.71, 599.72, 611.89, and 999.89 to the list of ICD-9-CM codes covered by Medicare for the Prothrombin Time (PT) (190.17) NCD.
- Delete ICD-9-CM codes 511.8, 599.7, 611.8, and 999.8 from the list of ICD-9-CM codes covered by Medicare for the Prothrombin Time (PT) (190.17) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Prothrombin Time (PT) (190.17) NCD.
For Serum Iron Studies:
- Add ICD-9-CM codes 199.2, 209.40, 209.41, 209.42, 209.43, 209.50, 209.51, 209.52, 209.53, 209.54, 209.55, 209.56, 209.57, 209.60, 209.61, 209.62, 209.63, 209.64, 209.65, 209.66, 209.67, 209.69, 209.30, 238.77, 571.42, 999.89, 209.00, 209.01, 209.02, 209.03, 209.10, 209.11, 209.12, 209.13, 209.14, 209.15, 209.16, 209.17, 209.20, 209.21, 209.22, 209.23, 209.24, 209.25, 209.26, 209.27, and 209.29 to the list of ICD-9-CM codes covered by Medicare for the Serum Iron Studies (190.18) NCD.
- Delete ICD-9-CM codes 999.8 and V15.2 from the list of ICD-9-CM codes covered by Medicare for the Serum Iron Studies (190.18) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Serum Iron Studies (190.18) NCD.
For Collagen Crosslinks:
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Collagen Crosslinks, Any Method (190.19) NCD.
For Blood Glucose Testing:
- Add ICD-9-CM codes 038.12, 707.20, 707.21, 707.22, 707.23, 707.24, 707.25, 780.72, V23.85, and V23.86 to the list of ICD-9-CM codes covered by Medicare for the Blood Glucose Testing (190.20) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Blood Glucose Testing (190.20) NCD.
For Glycated Hemoglobin/Glycated Protein:
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Glycated Hemoglobin/Glycated Protein (190.21) NCD.
For Thyroid Testing:
- Add ICD-9-CM codes 275.5, 780.72, 780.60, 780.61, 780.62, 780.63, 780.64, and 780.65 to the list of ICD-9-CM codes covered by Medicare for the Thyroid Testing (190.22) NCD.
- Delete ICD-9-CM code 780.6 from the list of ICD-9-CM codes covered by Medicare for the Thyroid Testing (190.22) NCD.
- Delete ICD-9-CM codes V28.8.and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Thyroid Testing (190.22) NCD.
For Lipid Testing:
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Lipids Testing (190.23) NCD.
For Digoxin Therapeutic Drug Assay:
- Add ICD-9-CM codes 275.5, 339.3, and 780.72 to the list of ICD-9-CM codes covered by Medicare for the Digoxin Therapeutic Drug Assay (190.24) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Digoxin Therapeutic Drug Assay (190.24) NCD.
For Alpha-Fetoprotein:
- Add ICD-9-CM codes 571.42, 209.20, 209.21, 209.22, 209.23, 209.24, 209.25, 209.26, 209.27, and 209.29 to the list of ICD-9-CM codes covered by Medicare for the Alpha-Fetoprotein (190.25) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Alpha-Fetoprotein (190.25) NCD.
For Carcinoembryonic Antigen:
- Add ICD-9-CM codes 209.00, 209.01, 209.02, 209.03, 209.10, 209.11, 209.12, 209.13, 209.14, 209.15, 209.16, 209.17, 209.20, 209.21, 209.22, 209.23, 209.24, 209.25, 209.26, 209.27, and 209.29 to the list of ICD-9-CM codes covered by Medicare for the Carcinoembryonic Antigen (190.26) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Carcinoembryonic Antigen (190.26) NCD.
For Human Chorionic Gonadotropin:
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Human Chorionic Donadotropin (190.27) NCD.
For Tumor Antigen by Immunoassay-CA125:
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Tumor Antigen by Immunoassay-CA125 (190.28) NCD.
For Tumor Antigen by Immunoassay-CA15-3/CA27.29:
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Tumor Antigen by Immunoassay-CA15-3/CA27.29 (190.29) NCD.
For Tumor Antigen by Immunoassay-CA19-9:
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Tumor Antigen by Immunoassay-CA19-9 (190.30) NCD.
For Prostate Specific Antigen (PSA):
- Add ICD-9-CM codes 599.70, 599.71, and 599.72 to the list of ICD-9-CM codes covered by Medicare for the Prostate Specific Antigen (PSA) (190.31) NCD.
- Delete ICD-9-CM code 599.7 from the list of codes covered by Medicare for the Prostate Specific Antigen (PSA) (190.31) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the (PSA) (190.31) NCD.
For Gamma Glutamyl Transferase:
- Add ICD-9-CM codes 275.5, 038.12, 209.20, 209.21, 209.22, 209.23, 209.24, 209.25, 209.26, 209.27, 209.29, 238.77, 558.41, 558.42, and 571.42 to the list of ICD-9-CM codes covered by Medicare for the Gamma Glutamyl Transferase (190.32) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Gamma Glutamyl Transferase (190.32) NCD.
For Hepatitis Panel/Acute Hepatitis Panel:
- Add ICD-9-CM code 780.72 to the list of ICD-9-CM codes covered by Medicare for the Hepatitis Panel/Acute Hepatitis Panel (190.33) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the Hepatitis Panel/Acute Hepatitis Panel (190.33) NCD.
For Fecal Occult Blood Test (FOBT):
- Add ICD-9-CM codes 209.40, 209.41, 209.42, 209.43, 209.50, 209.51, 209.52, 209.53, 209.54, 209.55, 209.56, 209.57, 209.00, 209.01, 209.02, 209.03, 209.10, 209.11, 209.12, 209.13, 209.14, 209.15, 209.16, 209.17, 530.13, 558.41, 558.42, 569.44, 571.42, and 780.72 to the list of ICD-9-CM codes covered by Medicare for the Fecal Occult Blood Test (FOBT) (190.34 ) NCD.
- Delete ICD-9-CM codes V28.8 and V68.0 from the list of ICD-9-CM codes denied by Medicare for the FOBT (190.34) NCD.
For All 23 NCDs (190.12-190.34):
- Add ICD-9-CM codes V28.81, V28.82, V28.89, V68.01, and V68.09 to the list of denied ICD-9-CM codes for all 23 Lab NCDs.
Additional Information
The official instruction, CR 6213, issued to your carrier, FI, or A/B MAC regarding this change may be viewed at
If you have any questions, please contact our Provider Contact Center at our toll free number, (866) 332-7025.
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 2007 American Medical Association.