Pathology/Lab Coding Alert

Question: Our lab frequently faces denials on thyroid function test claims. Why does this happen?


Virginia Subscriber


Answer:  Several factors may cause your denials. CMS has a National Coverage Determination on thyroid testing that outlines the coverage criteria for these procedures. Your best bet is to consult the NCD and learn the billing requirements for thyroid function tests. Of course, some private payers may publish slightly different requirements, so you should also check with the payer that denied your claim.

Medicare does not cover screening tests of any kind, including screening for thyroid disorders (V77.0). According to the Medicare NCD, "tests for screening purposes that are performed in the absence of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicitly authorized by statute." The NCD provides an exhaustive list of the ICD-9 codes that Medicare will deny and also a list of the acceptable diagnosis codes. Acceptable codes include malignant neoplasm of thyroid gland (193), premature menopause (256.31), fever (780.6), abnormal weight gain (783.1), throat pain (784.1), and many more.

If the NCD doesn't lead you to the right information, determine whether your patient may have exceeded the frequency limits for these tests. The NCD states that "testing may be covered up to two times a year in clinically stable patients," but Medicare may reimburse more frequent testing based on necessity.