Medical necessity for full wellness panel

nestes22

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I work in a Diagnostic Lab, we get an overwhelming amount of orders for diagnostic tests with diagnosis codes that do not support the medical need for testing. Therefore we are seeing a dramatic loss in revenue on our medicare claims. However, according CMS guidelines we at the lab are not allowed to "add" codes. Being a coder, that's tough because I feel limited in how I can correct the problem and I have a confusing interpretation of the word "add" as it is used.

With that said my questions are as follows:

1.) When CMS states labs can not "add" codes, does this mean that we can never code a charts/medical record that we receive for testing, ever, or does it simply mean that if we do, we are held to the same standard of - "if it isn't documented it didn't happen" - from the physicians notes?



Also, I've notice a lot of our orders come in for a full wellness panel with one diagnosis M54.16. Would M54.16 (Radiculopathy, Lumbar Region) support the medical need for the following CPT codes that are included in our full wellness panels? I have consulted the NCD list of supported ICD-10 codes and it is not listed in the covered or non-covered list of supporting medical necessity which would mean that it is not one covered by medicare, right? Just wanting to clarify to see if my findings are correct or if it would infact be covered...

85025
80053
82533
82627
82670
82728
82746
83001
83036
83003
84305
83520
83970
83540
83550
80061
83002
83735
84144
84146 or 84153
84270
84481
84439
84403
84443
82607
82306

Any help is greatly appreciated!
 
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nestes22

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Maybe a better question is actually if something is specifically excluded from Medicare coverage, can't we just bill the patient directly unless the patient requests that Medicare be billed first?
 
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Possible solution

Since you are unable to add diagnosis codes, you might contact the doctors office and explain that the lab procedures do not meet medical necessity and would require a diagnosis that would support the codes. If the doctor cannot document a dx code to support the reason for the tests, he probably shouldn't be ordering them. If its a medicare patient and you know it will be denied, inform the doctors office they should have the patient sign an ABN so it will be legal to bill for any denials due to lack of medical necessity.
 

nestes22

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Good advice, thank you. I'm just taking over all the Medicare claims for my office and figuring everything out from how it's supposed to be done compared to how they currently do things is rough. Getting better by the day though :)
 
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