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October 13, 2009:

Those providing lab services should take particular note of the latest update of the edit module for clinical diagnostic laboratory services. Among the updates are several that affect some frequently used codes.

The October 2009 release of the edit module started affecting claims October 1. This module, which includes national coverage determinations (NCDs), is updated quarterly to incorporate coding decisions and updates to the ICD-9-CM codes. The last release of the edit module was July 2009.

Medicare and other payers will pay only for clinical laboratory tests that are reasonable and necessary to treat or diagnose an individual patient, and the treating physician is responsible for ordering medically appropriate tests with supporting diagnostic information. There must be a physician’s order for each test and a diagnosis specific to that particular patient. For example, prothrombin time (85610) ordered with a diagnosis of anticoagulation therapy (V58.61) is reasonable and necessary. Effective October 1, 2009, 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 have all been added to the list of diagnosis codes that are covered by Medicare for the prothrombin time.

A laboratory must report the diagnosis code furnished by the ordering physician and may not report one in the absence of physician-supplied diagnostic information supporting that code. Section 4317(b) of the Balanced Budget Act requires the ordering physician to provide the diagnosis code or a narrative diagnosis at the time the test is ordered. Frequently, however, orders do not include sufficient information, resulting in denials of laboratory services. For instance, “rule out,” “suspected,” or “probable” diagnoses may not be coded; instead, the ordering physician should provide information related to the suspected condition such as signs and symptoms.

ICD-9-CM code V72.6 Laboratory examination is often used—and often denied because most payers have specific coverage guidelines, especially for routine tests such as annual physical examinations and screening tests without signs or symptoms. Effective October 1, 2009, code V72.6 has been expanded to provide specific codes to report laboratory services for antibody testing, general medical examinations, and pre-procedural circumstances. Unfortunately, effective for services furnished on or after October 1, these new codes (V72.60–V72.63, V72.69) have been added to the list of codes that do not support medical necessity for clinical diagnostic laboratory coverage of blood counts (85007–85009, 85013–85014, 85018, 85021–85025, 85027, 85031).

Some of the other changes effective October 1, 2009, include:

  • ICD-9-CM codes 209.70–209.75, 209.79, 285.3, 569.87, 787.04, 789.7, and 995.24 will be covered by Medicare for the fecal occult blood test.
  • ICD-9-CM codes now covered by Medicare for bacterial urine cultures include 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.
  • Medicare will also pay for serum iron studies with 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.
  • Codes that are covered by Medicare for the partial thromboplastin time (PTT) now include 453.50–453.52, 453.6, 453.71–453.77, 453.79, 453.81–453.87, 453.89, 789.7, and 995.24.

Hospitals, laboratories, physicians, and other providers are advised to ensure their staffs are aware of the changes to avoid delays in testing as well as claim denials.

The official instructions (change request 6548) and a related article may be found on the CMS website at: http://www.cms.hhs.gov/Transmittals/downloads/R1766CP.pdf and http://www.cms.hhs.gov/mlnmattersarticles/downloads/MM6548.pdf.

Sarah A. Serling, CPC, CPC-H, CPC-I, CCS-P, CCS
Clinical/Technical Editor


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