Denial Reason, Reason/Remark Code(s)
- CO-50: These are non-covered services because this is not deemed a 'medical necessity' by the payer
- CPT code: 80061
Resolution/Resources
CMS has established national guidelines related to lipid panels as a National Coverage Determination (NCD), effective January 1, 2003. The most important step you can take is to check the NCD guidelines before you submit a claim.
NCDs apply to all Medicare Fee for Service contractors and provide a uniform set of instructions for processing claims for these services. NCDs for these tests specify:
- Indications: in what circumstances is the test considered 'medically necessary'?
- Limitations: in what circumstances is the test contraindicated? Are there frequency parameters for Medicare coverage?
- CPT or HCPCS codes included in the NCD
- ICD-9-CM codes covered by the Medicare program
Other Facts about Clinical Laboratory Tests
- The complete NCD for lipid panels is available on the CMS Web site at www.cms.hhs.gov/mcd and in the CMS National Coverage Determinations manual (PDF, 248 KB) (Pub. 100-03, part 3, section 190.23)
- Refer to the Medicare National Coverage Determinations Coding Policy Manual and Change Report for information regarding:
- Specific CPT and HCPCS codes included in the NCD
- Covered ICD-9-CM codes (part of the 'laboratory edit module')
- ICD-9-CM codes that are 'never covered' for any laboratory NCD
- You may also download the entire Lab Code List from this Web page
- The covered ICD-9-CM code list changes as often as quarterly for these NCDs; the list may differ depending upon the date of service
- The ICD-9-CM code reported on the claim must be the most specific code available that accurately reflects the primary reason the test was ordered/performed
- The patient's medical record must support the use of the ICD-9-CM code(s) reported on the claim
- Certain ICD-9-CM codes are designated as 'never covered' by Medicare
- NCDs exist for other clinical laboratory tests
Advance Beneficiary Notice Information
- Be aware of coverage restrictions before you submit a claim. If Medicare will not cover the test based on the patient's condition, you may ask the patient to sign an Advance Beneficiary Notice. For more information on ABNs, refer to the Beneficiary Notices Initiative page on the CMS Web site at www.cms.hhs.gov/BNI/01_overview.asp.
- ABNs must be issued using the standard CMS form. For services provided on or after March 1, 2009, you must use the revised CMS ABN if you are providing advance notice to a beneficiary. Acess the revised ABN and other background information from the CMS Web site: www.cms.hhs.gov/BNI/01_overview.asp.
- If you have obtained a valid ABN, submit claims for this service with HCPCS modifier GA. Refer to the Palmetto GBA Modifier Lookup tool for information on HCPCS modifier GA.