Pathology/Lab Coding Alert

While the implementation of Medicare's 23 National Coverage Decisions (NCDs) has brought confusion to many labs, you can gain some clarity here.

Medicare's edit software missed the Nov. 25 deadline (see "Labs May Wait for NCD Claims" in the September 2002 Pathology/Lab Coding Alert ), and carriers' instructions to labs have been mixed.

"We were told in September by our carrier to download a 234-page document and inform our clients of the changes by Nov. 25," says Stan Werner, MT (ASCP), administrative director of Peterson Clinical Laboratory in Manhattan, Kan. Others received little direction aside from their carriers removing long-standing local medical review policies (LMRPs) for certain lab tests. The NCDs impact diagnosis and CPT coding for more than 60 lab tests (see "Clinical Laboratory National Coverage Decisions" p. 94), representing about 60 percent of lab claims, CMS says. That's why you need to know the answers to the following commonly asked questions: Q: Two dates are circulating in the lab community for the NCDs: Nov. 25, 2002, and Jan. 1, 2003. When are the NCDs effective, and why do we hear these two different dates? A: The NCDs are effective for services provided on or after Nov 25. However, Medicare's edit software, which allows carriers and fiscal intermediaries (FIs) to process claims under the new rules, won't be in place until Jan. 1, 2003. Starting Nov. 25, you should submit claims in accordance with the NCDs because carriers and FIs can go back and review these claims and make adjustments once the edit software is available in January. Q: Some Medicare carriers have removed from their Web sites LMRPs for procedures such as complete blood count (CBC). How do we know which ICD-9 codes support medical necessity for a procedure if the LMRP is gone? A: Medicare instructed carriers to remove LMRPs that conflict with NCDs by Nov. 25. Even though carriers cannot review claims under the new rules until the edit software is available, removal of conflicting LMRPs should eliminate erroneous edits and denials. You can find the ICD-9 codes that support medical necessity in the NCD from your carrier or CMS Program Memorandum AB-02-110 available at http://www.cms.gov/manuals/pm_trans/AB02110.pdf. Remember, CBC is an "exclusionary" NCD, meaning it does not list the covered codes, only those expected to be denied (see next question). Q: In addition to a list of "ICD-9-CM Codes Covered by Medicare Program," each NCD also lists diagnosis codes under the headings "ICD-9-CM Codes Denied" and "ICD-9-CM Codes That Do Not Support Medical Necessity." What is the difference between the latter two lists, and how should we report codes from them? A: Each NCD accounts for every ICD-9 code in [...]