Untangle Thyroid Testing Coverage Rules
Published on Thu Aug 01, 2002
Complex coverage issues impact coding and reimbursement for lab tests used to diagnose and monitor thyroid disorders. Medical-necessity indications, as well as frequency limits and recent clinical advances in laboratory methods, dictate reporting requirements for these services.
"Not only do many Medicare carriers have local medical review policies (LMRPs) that govern coverage, but a thyroid testing national coverage decision will become effective in November of this year," says William Dettwyler, MT-AMT, coding analyst for Health Systems Concepts, a laboratory coding and compliance consulting firm in Longwood, Fla. Coupled with national Correct Coding Initiative (CCI) edits, these rules impact payment for thyroid testing services based on diagnosis and procedure coding. Know Indications for Thyroid Function Tests Thyroid function tests are indicated to define thyroid disease of over- or underproduction of hormones. Medicare and many third-party payers consider thyroid testing reasonable and necessary to 1) confirm or rule out primary hypothyroidism or hyperthyroidism, 2) distinguish between primary and secondary hypothyroidism, 3) monitor progression of disease and therapy in patients with thyroid dysfunction, and 4) monitor neoplasm of the thyroid or other endocrine glands.
Physicians often order thyroid function tests when clinical signs and symptoms indicate possible abnormalities of the thyroid or pituitary glands.
"Many indistinct clinical complaints may arouse a suspicion of thyroid dysfunction, so Medicare and most insurers allow certain thyroid tests based on a long list of ICD-9 symptom codes," Dettwyler says. These include symptoms described throughout the ICD9 Codes, such as malnutrition (263.0-263.9), depression (311), constipation (564.0x), and dysmenorrhea (625.3). Many insurers also pay for thyroid function tests based on codes from ICD-9's "symptoms, signs, and ill-defined conditions" section (780-799), such as insomnia (780.50-780.52), abnormal weight gain or loss (783.1 or 783.2x), palpitations (785.1) or nervousness (799.2).
"Thyroid function tests are not covered for screening, so you should report any of these signs and symptoms described by the ordering physician as the reason for the test, no matter how vague they may seem," Dettwyler cautions. Commonly covered thyroid tests for these diagnoses include: 84436 Thyroxine; total (often ordered as T4 or TT4) 84439 Thyroxine; free (often ordered as FT4, Free T4, or FTI) 84443 Thyroid stimulating hormone (TSH) 84479 Thyroid hormone (T3 orT4) uptake or thyroid hormone binding ratio (THBR). These tests are also covered for confirmed thyroid or other endocrine system diagnoses, such as neoplasm (e.g., 193, 194.8, 198.89, 226), goiter (240-241), hypothyroidism (243-244), and other thyroid disorders (e.g., 246). "The national coverage policy and many individual LMRPs and private insurers provide an exhaustive list of acceptable diagnoses to indicate medical necessity for thyroid function tests," Dettwyler says.
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