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MIR-2006-10AB, October 2006
Changes to the Laboratory National Coverage Determination (NCD) Edit Software for October 2006
Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare carriers and fiscal intermediaries (FIs) for clinical diagnostic laboratory services provided for Medicare beneficiaries
Impact on Providers
This article is based on Change Request (CR) 5293, which announces the changes that will be included in the October 2006 release of the edit module for clinical diagnostic laboratory services.
Background
The National Coverage Determinations (NCDs) for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published as a final rule on November 23, 2001. Subsequently, the Centers for Medicare & Medicaid Services (CMS) contracted for nationally uniform software to be developed and incorporated into its shared systems so that laboratory claims subject to one of the 23 NCDs can be processed uniformly throughout the nation effective January 1, 2003. The 23 national coverage determinations are listed below:
1. Culture, Bacterial, Urine
2. Human Immunodeficiency Virus Testing (Prognosis including monitoring)
3. Human Immunodeficiency Virus Testing (Diagnosis)
4. Blood Counts
5. Partial Thromboplastin Time
6. Prothrombin Time
7. Serum Iron Studies
8. Collagen Crosslinks, Any Method
9. Blood Glucose Testing
10. Glycated Hemoglobin/Glycated Protein
11. Thyroid Testing
12. Lipids
13. Digoxin Therapeutic Drug Assay
14. Alpha-fetoprotein
15. Carcinoembryonic Antigen
16. Human Chorionic Gonadotropin
17. Tumor Antigen by Immunoassay - CA125
18. Tumor Antigen by Immunoassay CA 15-3/CA 27.29
19. Tumor Antigen by Immunoassay CA 19-9
20. Prostate Specific Antigen
21. Gamma Glutamyl Transferase
22. Hepatitis Panel/Acute Hepatitis Panel
23. Fecal Occult Blood
The laboratory edit module for the NCDs is updated quarterly (as necessary) to reflect coding updates and substantive changes to the NCDs developed through the NCD process. (See the Medicare Claims Processing Manual (Pub.100-4), Chapter 16, §120.2, http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf.  )
CR5293 informs your Medicare carrier and FI about changes in the laboratory NCD code lists for October 2006, that require updating of the laboratory edit module. These changes become effective for services furnished on or after October 1, 2006.
Changes are being made to the NCD code lists for services furnished on or after October 1, 2006, and are as follows:
190.12 - Urine Culture, Bacterial
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Urine Culture, Bacterial (190.12) NCD:
- ICD-9-CM codes 288.00, 288.01, 288.02, 288.03, 288.04, 288.09, 608.20, 608.21, 608.22, 608.23, 608.24, 616.81, 616.89, 780.96, 780.97, 788.64, and 788.65.
The following ICD-9-CM codes are being deleted from the list of ICD-9-CM codes covered by Medicare for the Urine Culture, Bacterial (190.12) NCD:
- ICD-9-CM codes 288.0, 608.2, and 616.8.
190.14 - Human Immunodeficiency Virus (HIV) Testing (Diagnosis)
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Human Immunodeficiency Virus (HIV) Testing (Diagnosis) (190.14) NCD:
- ICD-9-CM codes 052.2, 053.14, 054.74, 288.00, 288.01, 288.02, 288.03, 288.04, 288.09, 288.4, 288.50, 288.51, 288.59, 288.60, 288.61, 288.62, 288.63, 288.64, 288.65, 288.69, 289.53, and 331.83.
The following ICD-9-CM code is being deleted from the list of ICD-9-CM codes covered by Medicare for the Human Immunodeficiency Virus (HIV) Testing (Diagnosis) (190.14) NCD:
190.15 - Blood Counts
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes that do not support medical necessity for the Blood Counts (190.15) NCD:
- ICD-9-CM codes 338.0, 338.11, 338.12, 338.18, 338.19, 338.21, 338.22, 338.28, 338.29, 338.4, 389.15, 389.16, 478.11, 478.19, 521.81, 521.89, 525.60, 525.61, 525.62, 525.63, 525.64, 525.65, 525.66, 525.67, 525.69, 526.61, 526.62, 526.63, 526.69, 608.20, 608.21, 608.22, 608.23, 608.24, 618.84, V26.34, V26.35, V45.86, V72.11, and V72.19.
- ICD-9-CM codes 521.8 and V72.1 are deleted from the list of codes that do not support medical necessity for the Blood Counts (190.15) NCD.
190.16 - Partial Thromboplastin Time (PTT)
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Partial Thromboplastin Time (PTT) (190.16) NCD:
- ICD-9-CM codes 238.71, 238.72, 238.73, 238.74, 238.75, 238.76, 238.79, 277.30, 277.31, 277.39, 289.81, 649.30, 649.31, 649.32, 649.33, 649.34, 649.50, 649.51, 649.53, 998.12, 995.20, 995.21, 995.27, and 995.29.
The following ICD-9-CM codes are being deleted from the list of ICD-9-CM codes covered by Medicare for the Partial Thromboplastin Time (PTT) (190.16) NCD:
- ICD-9-CM codes 238.7, 277.3, and 995.2.
190.17 - Prothrombin Time (PT)
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Prothrombin Time (PT) (190.17) NCD:
- ICD-9-CM codes 238.71, 238.72, 238.73, 238.74, 238.75, 238.76, 238.79, 277.30, 277.31, 277.39, 289.81, 649.30, 649.31, 649.32, 649.33, 649.34, 649.50, 649.51, 649.53, 995.20, 995.21, 995.27, and 995.29.
The following ICD-9-CM codes are being deleted from the list of ICD-9-CM codes covered by Medicare for the Prothrombin Time (PT) (190.17) NCD:
- ICD-9-CM codes 238.7, 277.3, and 995.2.
190.18 - Serum Iron Studies
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Serum Iron Studies (190.18) NCD:
- ICD-9-CM codes 238.71, 238.72, 238.73, 238.74, 238.75, 238.76, and 238.79.
The following ICD-9-CM code is being deleted from the list of ICD-9-CM codes covered by Medicare for the Serum Iron Studies (190.18) NCD:
190.20 - Blood Glucose Testing
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Blood Glucose Testing (190.20) NCD:
- ICD-9-CM codes 331.83, 528.00, 528.09, 649.20, 649.21, 649.22, 649.23, 649.24, and 780.32.
The following ICD-9-CM code is being deleted from the list of ICD-9-CM codes covered by Medicare for the Blood Glucose Testing (190.20) NCD:
190.22 - Thyroid Testing
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Thyroid Testing (190.22) NCD:
- ICD-9-CM codes 331.83, 780.96, and 780.97.
The following ICD-9-CM code is being deleted from the list of ICD-9-CM codes covered by Medicare for the Thyroid Testing (190.22) NCD:
190.23 - Lipids Testing
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Lipids Testing (190.23) NCD:
- ICD-9-CM codes 277.30, 277.31, and 277.39.
The following ICD-9-CM code is being deleted from the list of ICD-9-CM codes covered by Medicare for the Lipids Testing (190.23) NCD:
190.24 - Digoxin Therapeutic Drug Assay
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Digoxin Therapeutic Drug Assay (190.24) NCD:
- ICD-9-CM codes 995.20, 995.21, 995.27, and 995.29.
The following ICD-9-CM code is being deleted from the list of ICD-9-CM codes covered by Medicare for the Digoxin Therapeutic Drug Assay (190.24) NCD:
190.25 - Alpha-fetoprotein
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Alpha-fetoprotein (190.25) NCD:
- ICD-9-CM codes V86.0, V86.1, 795.89 and 338.3.
190.26 - Carcinoembryonic Antigen
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Carcinoembryonic Antigen (190.26) NCD:
- ICD-9-CM codes 795.81, 795.89, and 338.3.
190.27 - Human Chorionic Gonadotropin
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Human Chorionic Gonadotropin (190.27) NCD:
- ICD-9-CM codes 795.89 and 338.3.
190.28 - Tumor Antigen by Immunoassay CA 125
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Tumor Antigen by Immunoassay CA 125 (190.28) NCD:
- ICD-9-CM codes 795.82, 795.89, and 338.3.
190.29 - Tumor Antigen by Immunoassay CA 15-3/CA27.29
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Tumor Antigen by Immunoassay CA 15-3/CA27.29 (190.29) NCD:
- ICD-9-CM codes 338.3 and 795.89.
190.30 - Tumor Antigen by Immunoassay CA 19.9
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Tumor Antigen by Immunoassay CA 19.9 (190.30) NCD:
- ICD-9-CM codes 338.3 and 795.89.
190.31 - Prostate Specific Antigen (PSA)
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Prostate Specific Antigen (PSA) (190.31) NCD:
- ICD-9-CM codes 600.00, 600.10, 600.11, 600.21, 788.64, and 788.65.
190.32 - Gamma Glutamyl Transferase (GGT)
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Gamma Glutamyl Transferase (GGT) (190.32) NCD:
- ICD-9-CM codes 238.71, 238.72, 238.73, 238.74, 238.75, 238.76, 238.79, 277.30, 277.31, and 277.39.
The following ICD-9-CM codes are being deleted from the list of ICD-9-CM codes covered by Medicare for the Gamma Glutamyl Transferase (GGT) (190.32) NCD:
- ICD-9-CM codes 238.7 and 277.3.
190.33 - Hepatitis Panel/Acute Hepatitis Panel
The ICD-9-CM code 780.32 is being added to the list of ICD-9-CM codes covered by Medicare for the Hepatitis Panel/Acute Hepatitis Panel (190.33) NCD.
190.34 - Fecal Occult Blood Test (FOBT)
The following ICD-9-CM codes are being added to the list of ICD-9-CM codes covered by Medicare for the Fecal Occult Blood Test (FOBT) (190.34) NCD:
- ICD-9-CM codes 284.2 and 338.3.
The following ICD-9-CM code is being deleted from the list of ICD-9-CM codes covered by Medicare for the Fecal Occult Blood Test (FOBT) (190.34) NCD:
List of Denied ICD-9-CM Codes for All NCDs
The following ICD-9-CM codes are being added to the list of denied ICD-9-CM codes for all NCDs:
- ICD-9-CM codes V18.51, V18.59, V82.71, and V82.79.
ICD-9-CM code V18.5 is deleted from the list of denied ICD-9-CM codes for all NCDs.
Implementation
The implementation date for CR5293 is October 2, 2006.
Additional Information
To see the official instruction issued to your carrier/intermediary regarding this change. That instruction may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1050CP.pdf on the CMS Web site.
If you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM5293
Pub. 100-4, Transmittal# R1050CP, CR# 5293
Related CR Release Date: September 7, 2006
Effective Date: October 1, 2006
Implementation Date: October 2, 2006
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