Issue 2006-04, April 2006

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for April 2006

Provider Types Affected
Physicians, suppliers, and providers billing Medicare carriers and/or fiscal intermediaries (FIs) for clinical diagnostic laboratory services

Provider Action Needed

Impact to You
This article is based on Change Request (CR) 4328, which announces the implementation of changes to the list of codes associated with the 23 negotiated laboratory NCDs, and the update of the laboratory edit module for changes in the laboratory NCD code lists for April 2006.

What You Need to Know
The changes to the list of codes are a result of coding analysis decisions developed under the procedures for maintenance of codes in the negotiated NCDs. Several of the listed changes correct codes to reflect the recent Current Procedural Terminology (CPT) update and are necessary so that the laboratory edit module will appropriately process claims using the most current negotiated laboratory NCDs and code lists.

What You Need to Do
See the Background section of this article for further details regarding these changes.

Background
In accordance with the Balanced Budget Act of 1997 (Section 4554), the Centers for Medicare & Medicaid Services (CMS) entered into negotiated rulemaking proceedings to develop national coverage determinations (NCDs) for clinical diagnostic laboratory services. Under the negotiations, CMS developed 23 laboratory NCDs, and these NCDs are different than most other Medicare NCDs in that they include lists of ICD-9-CM codes. All codes are included on one of the following lists:

• Covered codes;
• Not covered codes; and
• Codes that do not support medical necessity.

Nationally uniform software was developed by Computer Sciences Corporation (CSC) and incorporated in the shared systems so that laboratory claims subject to one of the 23 NCDs are processed uniformly throughout the nation effective January 1, 2003. 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 (Publication 100-4, Chapter 16, Section 120.2, at http://www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage on the CMS Web site.)

CMS updates the NCD code list quarterly as necessary to incorporate new codes, correct ministerial errors, incorporate the results of Coding Analysis published elsewhere on this site, and incorporate reconsideration of the NCDs that alter covered indications. The quarterly updates are published in the NCD Coding Policy Manual, and you can download the current and previous coding manuals from this site. Alternatively, you can access individual NCDs from the lab index included on the following CMS Web site: http://www.cms.hhs.gov/mcd/index_section.asp?ncd_sections=40.

 Change Request (CR) 4238 announces the changes that will be included in the April 2006 release of the edit module for clinical diagnostic laboratory services. The changes are a result of coding analysis decisions developed under the procedures for maintenance of codes in the negotiated NCDs. Several of the listed changes correct codes to reflect the current CPT update. CR4238 communicates requirements to the laboratory edit module to update it for the following changes in laboratory NCD code lists for April 2006:

Blood Count NCD
Add the following ICD-9-CM code to the list of codes that do not support medical necessity for the Blood Count NCD:

ICD-9-CM Codes Never Covered by Medicare

Delete the following ICD-9-CM code from the list of ICD-9-CM codes never covered by Medicare:

Fecal Occult Blood Test NCD

Add the following new CPT code to the list of HCPCS/CPT codes covered by Medicare for Fecal Occult Blood Test NCD:

Delete the following CPT code from the HCPCS/CPT code list for Fecal Occult Blood Test NCD:

Hepatitis Panel/Acute Hepatitis Panel NCD

Add the following ICD-9-CM code to the list of ICD-9-CM codes covered by Medicare for Hepatitis Panel/Acute Hepatitis Panel NCD:

 Lipids Testing NCD

Add the following new CPT codes to the list of HCPCS/CPT codes covered by Medicare for Lipids Testing NCD:

Delete the following CPT codes from the HCPCS/CPT code list for Lipids Testing NCD:

Urine Culture, Bacterial NCD
Delete Coding Guideline 1 in the Urine Culture, Bacterial NCD, and renumber the remaining Coding Guidelines.

Implementation
The implementation date for the instruction is April 3, 2006.

Additional Information
For complete details, please 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/R864CP.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/apps/contacts/ on the CMS Web site.

The following table includes the list of all twenty-three (23) Laboratory National Coverage Determinations, and each NCD can be reviewed at http://www.cms.hhs.gov/mcd/index_section.asp?ncd_sections=40 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.

Related Change Request (CR) #: 4328
Medlearn Matters Number: MM4328
Related CR Release Date: February 17, 2006
Effective Date: April 1, 2006
Related CR Transmittal #: R864CP
Implementation Date: April 3, 2006