The Centers for Medicare & Medicaid Services (CMS), formerly HCFA, is responsible for administering the Medicare program throughout the United States. In order to ensure that services paid for by the Medicare program are indeed medically necessary, CMS has identified laboratory tests that require medical necessity documentation. These are called National Coverage Determinations or NCD's. CMS also authorizes local carriers to establish their own list of tests which are called Local Medical Review Policies (LMRP's) or limited coverage tests.
Medicare carriers have developed systems using ICD-9 diagnosis codes to prevent the payment of claims they determine are not medically necessary. Under these policies, NCD's and LMRP's, the patient's diagnosis and the policies determine medical necessity. It is critical that the ICD-9 code used for ordering laboratory services be consistent with the documentation in the patient's medical records so that the medical necessity information is clear and apparent in the event of a post payment review. The ICD-9 code used must be specific to a particular patient and the laboratory tests ordered by the physician for that date of service. |
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