MMA - Changes to the Laboratory National Coverage Determination (NCD) Edit Software for January 2005

Provider Types Affected
Clinical diagnostic laboratories

Provider Action Needed
CR 3429 announces changes to the list of codes associated with the 23 negotiated laboratory National Coverage Determinations (NCDs). These changes are:

• A result of coding analysis completed by the Centers for Medicare & Medicaid Services (CMS); and
• Necessary to implement the cardiovascular and diabetes screening benefits added to Medicare under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA).

Background
The NCDs for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published as a final rule on November 23, 2001. Also, nationally uniform software was developed by Computer Sciences Corporation and incorporated into the shared systems so that laboratory claims subject to any of the 23 NCDs are processed uniformly throughout the nation, effective January 1, 2003.

In addition, the laboratory edit module for the NCDs is updated quarterly as necessary to reflect ministerial coding updates and substantive changes to the NCDs developed through the NCD process. (See the Medicare Claims Processing Manual, Pub. 100-4, Chapter 16, Section 120.2.)

CR 3429 announces changes that will be included in the January 2005 release of the edit module for clinical diagnostic laboratory services.

In accordance with the coding analysis published on the coverage Internet site on July 26, 2004, CMS is implementing the following:

• For the urine culture and serum iron studies NCD, CMS is deleting the following code from the list of ICD-9-CM codes covered by Medicare: V72.84 (Pre-operative examination, unspecified).

Coverage for this code will terminate for services furnished on or after January 1, 2005. See:  http://cms.hhs.gov/mcd/viewdecisionmemo.asp?id=127 .

In accordance with the coding analysis published on the coverage Internet site on July 27, 2004, CMS is implementing the following changes:

• For the tumor antigen by immunoassay CA 125 NCD, CMS is adding the following diagnosis codes to the list of ICD-9-CM codes covered by Medicare:

Coverage for these codes will begin for services furnished on or after January 1, 2005. See: http://cms.hhs.gov/mcd/viewdecisionmemo.asp?id=132 .

In accordance with the coding analysis published on the coverage Internet site on July 28, 2004, CMS is implementing the following change:

• For the Prothrombin Time (PT) test NCD, CMS is removing the following diagnosis code from the list of ICD-9-CM codes covered by Medicare: V43.60 - Unspecified joint replaced by other means.

Coverage for this code will terminate for services furnished on or after January 1, 2005. See: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=131 .

To accommodate the new cardiovascular and diabetes screening benefits that were added to Medicare by the MMA, CMS is removing the following codes from the list of ICD-9-CM codes not covered by Medicare:

• V77.1 Screening for Diabetes Mellitus;
• V81.0 Screening for Ischemic Heart Disease;
• V81.1 Screening for Hypertension; and
• V81.2 Screening for Other Unspecified Cardiovascular Conditions.

In order to implement the new cardiovascular and diabetes screening benefits that were added to Medicare by the MMA, CMS is making the following changes.

The lipid NCD edit is being subdivided into two parts:

1. For Current Procedural Terminology (CPT) codes 80061 - Lipid panel, 82465 - Cholesterol, serum total, 83718 - Lipoprotein, direct, HDL, and 84478 - Triglycerides, CMS is adding the following diagnosis codes to the list of ICD-9-CM codes covered by Medicare:
2. • V81.0 Screening for Ischemic Heart Disease;
   • V81.1 Screening for Hypertension; and
   • V81.2 Screening for Other Unspecified Cardiovascular Conditions.
3. The covered codes list for the remaining CPT codes in the lipid NCD 83715 - Lipoprotein, blood: electrophoretic separation and quantitation, 83716 - High-resolution fractionation and quantitation of lipoprotein cholesterols, and 83721 - Direct measurement, LDL cholesterol, remain unchanged.

4. For the diabetes benefit, the blood glucose NCD edit is being subdivided into two parts.

   1. For CPT code 82947, CMS is adding the following diagnosis code to the list of ICD-9-CM Diagnosis Codes covered by Medicare: V77.1 - Screening for Diabetes Mellitus.
   2. The covered codes for the remaining CPT codes in the blood glucose NCD 82948 - Glucose, blood, strip, and 82962 - Glucose (monitors), remain unchanged.

Please note that, effective October 1, 2003, all claims for clinical diagnostic laboratory services submitted to Medicare must include ICD-9-CM diagnosis codes. Coding Guideline #1 of the laboratory NCDs has been amended to reflect this requirement, and the guideline now states, "Any claim for a clinical diagnostic laboratory service must be submitted with an ICD-9-CM diagnosis code. Codes that describe symptoms and signs, as opposed to diagnosis, should be provided for reporting purposes when a diagnosis has not been established by the physician."

Implementation
The implementation date for this instruction is January 3, 2005.

Additional Information
For complete details, please see the official instruction issued to your carrier/fiscal intermediary regarding this change. It may be viewed at: http://www.cms.hhs.gov/Transmittals/ .

From that Web page, look for CR 3429 in the CR NUM column on the right, and click on the file for that CR.

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/MedlearnProducts/downloads/CallCenterTollNumDirectory.pdf .

Disclaimer
Medlearn Matters articles are prepared as a service to the public and are not intended to grant rights or impose obligations. Medlearn Matters articles 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.

For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/MedlearnMattersArticles/ .

Pub. 100-4, Transmittal # 380, CR # 3429
Medlearn Matters Number: MM 3429

Effective Date: January 1, 2005
Implementation Date: January 3, 2005

Posted: 12/14/2004

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