Pathology/Lab Coding Alert

Question: We frequently receive denials for thyroid function tests, especially TSH. Why does this happen, and what can we do to improve payment for these tests?


West Virginia Subscriber
Answer: Several factors could cause your denials, and you should use the "explanation of benefits" or similar statement to understand why payers reject your claims.

A likely reason for thyroid-function test denial is that the ordering physician may consider TSH (84443, Thyroid stimulating hormone [TSH]) a screening test. Often, physicians want to "rule out" thyroid problems based on vague clinical symptoms, and they may not submit the lab request with a payable diagnosis.

Medicare and other payers only cover specific screening tests, and thyroid screening (V77.0, Special screening for thyroid disorders) is not on Medicare's list. According to CMS, "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."

But when a physician orders a TSH test, a symptom usually exists that could easily demonstrate medical necessity for the test. To see some of these, you can look at Medicare's National Coverage Determination (NCD) that outlines the coverage criteria for TSH and other thyroid tests. You'll find, for instance, that Medicare will pay for a TSH test on the basis of non-specific complaints such as fever (780.6), sleep disturbance (780.50), abnormal weight gain (783.1) or throat pain (784.1). Some private payers may publish slightly different requirements, so you should also check with the payer that denied your claim. Key: Ensure that when physicians order thyroid tests from the lab, they provide documentation of signs, symptoms or conditions that demonstrate medical necessity for the tests. If the lab doesn't have a payable diagnosis, you can try to obtain a signed advance beneficiary notification (ABN) to let the patient know that he may have to pay for the test.