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Medicare National and Local Coverage ... - Quest …

Quest , Quest diagnostics , any associated logos, and all associated Quest diagnostics registered or unregistered trademarks are the property of Quest diagnostics . All third party marks - and - are the property of their respective owners. 2015 Quest diagnostics Incorporated. All rights reserved Last Updated: Policies in this MLCP Reference Guide apply to testing performed at a Quest diagnostics facility and apply to Medicare National Coverage Determination Policy. This diagnosis code reference guide is provided as an aid to physicians and office staff in determining when an ABN (Advance Beneficiary Notice) is necessary. Diagnosis codes must be applicable to the patient s symptoms or conditions and must be consistent with documentation in the patient s medical record. Quest diagnostics does not recommend any diagnosis codes and will only submit diagnosis information provided to us by the ordering physician or his/her designated staff. The CPT codes provided are based on AMA guidelines and are for informational purposes only.

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Transcription of Medicare National and Local Coverage ... - Quest …

1 Quest , Quest diagnostics , any associated logos, and all associated Quest diagnostics registered or unregistered trademarks are the property of Quest diagnostics . All third party marks - and - are the property of their respective owners. 2015 Quest diagnostics Incorporated. All rights reserved Last Updated: Policies in this MLCP Reference Guide apply to testing performed at a Quest diagnostics facility and apply to Medicare National Coverage Determination Policy. This diagnosis code reference guide is provided as an aid to physicians and office staff in determining when an ABN (Advance Beneficiary Notice) is necessary. Diagnosis codes must be applicable to the patient s symptoms or conditions and must be consistent with documentation in the patient s medical record. Quest diagnostics does not recommend any diagnosis codes and will only submit diagnosis information provided to us by the ordering physician or his/her designated staff. The CPT codes provided are based on AMA guidelines and are for informational purposes only.

2 CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed. Please note this document has been updated with National Medicare changes effective 7/1/2015 Medicare National and Local Coverage Determination Policy OK Click policy below for Local MLCP Policy ToolDocument contains the below Medicare LocalLimited Coverage Policies for lab testing performed in OK Allergy Testing Assays for Vitamins and Metabolic Function Blood Folic Acid Serum Assays for Vitamins and Metabolic Function C-Reactive Protein HS A ssays for Vitamins and Metabolic Function Carnitine Assays for Vitamins and Metabolic Function Cell Function Assay withStimulation and Lymphocyte Transformation Assays for Vitamins and Metabolic Function Fibrinogen Assays for Vitamins and Metabolic Function Homocysteine Assays for Vitamins and Metabolic Function Assay Lipoprotein PLA2 Assays for Vitamins and Metabolic Function Vitamin B-6 Assays for Vitamins and Metabolic Function Vitamin B 12 Assays for Vitamins and Metabolic Function Vitamin D 1.

3 25-dihydroxy Assays for Vitamins and Metabolic Function Vitamin D, 25-hydroxy (IncludesFractions, If Performed) Assays for Vitamins and Metabolic Function - Non-Covered Tests\Frequency Biomarkers for Oncology Biomarkers Overview Flow Cytometry Frequency of Laboratory Tests Glucose Testing Frequency of Laboratory Tests Lipids Frequency of Laboratory Tests Thyroid Testing Molecular diagnostics : Genitouriinary Infectious Disease Testing Qualitative Drug Screening Services That Are Not Reasonable and Necessary Click here for National MLCP Policies ToolDocument contains information on National MedicareLimited Coverage Policies Alpha-Fetoprotein Blood Counts Blood Glucose Testing Carcinoembryonic Antigen Collagen Crosslinks - Any Method Digoxin Therapeutic Drug Assay Fecal Occult Blood Gamma Glutamyl Transferase Glycated Hemoglobin - Glycated Protein Hepatitis Panel/Acute Hepatitis Panel Human Chorionic Gonadotropin Human Immunodeficiency Virus (HIV) Testing(Diagnosis) Human Immunodeficiency Virus (HIV) Testing(Prognosis Including Monitoring) Lipids Testing Partial Thromboplastin Time (PTT) Prostate Specific Antigen Prothrombin Time (PT)

4 Serum Iron Studies Thyroid Testing Tumor Antigen by Immunoassay CA 15-3 CA Tumor Antigen by Immunoassay CA 19-9 Tumor Antigen by Immunoassay CA-125 Urine Culture, Bacterial08/13/2015 This list was compiled from Medicare s Limited Coverage Policies for informational and reference purposes only. For the most cu rrent information please reference Note: If the patient s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED. Quest , Quest diagnostics , any associated logos, and all associated Quest diagnostics registered or unregistered trademarks are the property of Quest diagnostics . All third party marks - and - are the property of their respective owners.

5 2015 Quest diagnostics Incorporated. All rights reserved Last Updated: LCD Description: In order for allergy testing to be considered reasonable and necessary by Medicare , antigens must meet all the following criteria - skin testing must be performed based on history and physical exam, proven efficacy as demonstrated through scientifically valid medical studies published in peer-review journal, and exist in the patient's environment with a reasonable probability of exposure. ICD-9-CM Codes that Support Medical Necessity The Allergy test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9 -CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9 -CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided.

6 Medicare Local Coverage Determination Policy - OK L35771 Allergy Testing (Page 1 of 3) CPT Code: 82785, 86003 Data Source: 08/13/15 Aspergillosis Other Atopic Dermatitis And Related Conditions Allergic Urticaria Dermatographic Urticaria Toxic Effect Of Venom Toxic Effect Of Latex OTHER ANAPHYLACTIC Reaction Anaphylactic Reaction Due To Unspecified Food Anaphylactic Reaction Due To Peanuts Anaphylactic Reaction Due To Crustaceans Anaphylactic Reaction Due To Fruits And Vegetables Anaphylactic Reaction Due To Tree Nuts And Seeds Anaphylactic Reaction Due To Fish Anaphylactic Reaction Due To Food Additives Anaphylactic Reaction Due To Milk Products Anaphylactic Reaction Due To Eggs Anaphylactic Reaction Due To Other Specified Food * Personal History Of Unspecified Infectious And Parasitic Disease Other Follow-up Examination *Note: Personal History of infectious and parasitic disease should be used for recurrent pyogenic infections. FOR CPTs 82785 AND 86003 This list was compiled from Medicare s Limited Coverage Policies for informational and reference purposes only.

7 For the most cu rrent information please reference Note: If the patient s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED. Quest , Quest diagnostics , any associated logos, and all associated Quest diagnostics registered or unregistered trademarks are the property of Quest diagnostics . All third party marks - and - are the property of their respective owners. 2015 Quest diagnostics Incorporated. All rights reserved Last Updated: LCD Description: In order for allergy testing to be considered reasonable and necessary by Medicare , antigens must meet all the following criteria - skin testing must be performed based on history and physical exam, proven efficacy as demonstrated through scientifically valid medical studies published in peer-review journal, and exist in the patient's environment with a reasonable probability of exposure.

8 ICD-9-CM Codes that Support Medical Necessity The Allergy test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9 -CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9 -CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. Medicare Local Coverage Determination Policy - OK L35771 Allergy Testing (Page 2 of 3) CPT Code: 82785, 86003 Data Source: 08/13/15 Acute Conjunctivitis Unspecified Acute Atopic Conjunctivitis Vernal Conjunctivitis Other Chronic Allergic Conjunctivitis Acute Serous Otitis Media Other And Unspecified Chronic Nonsuppurative Otitis Media Unspecified Otitis Media Acute Maxillary Sinusitis Acute Frontal Sinusitis Acute Ethmoidal Sinusitis Acute Sphenoidal Sinusitis Other Acute Sinusitis Acute Sinusitis Unspecified 462 Acute Pharyngitis 463 Acute Tonsillitis Acute Laryngitis Without Obstruction Acute Laryngitis With Obstruction Supraglottitis Unspecified Without Obstruction Supraglottitis Unspecified With Obstruction Acute Bronchitis Polyp Of Nasal Cavity Other Polyp Of Sinus Unspecified Nasal Polyp Chronic Maxillary Sinusitis Chronic Frontal Sinusitis Chronic Ethmoidal Sinusitis Allergic Rhinitis Due To Pollen Allergic Rhinitis Due To Other Allergen Allergic Rhinitis Cause Unspecified Hypertrophy Of Nasal Turbinates Other Disease Of Nasal Cavity

9 And Sinuses Extrinsic Asthma Unspecified Extrinsic Asthma With Status Asthmaticus Extrinsic Asthma With (Acute) Exacerbation Intrinsic Asthma Unspecified Intrinsic Asthma With Status Asthmaticus Intrinsic Asthma With (Acute) Exacerbation Chronic Obstructive Asthma Unspecified Chronic Obstructive Asthma With Status Asthmaticus Chronic Obstructive Asthma With (Acute) Exacerbation Exercise-induced Bronchospasm Cough Variant Asthma Asthma Unspecified Asthma Unspecified Type With Status Asthmaticus Asthma Unspecified With (Acute) Exacerb Other Specified Gastritis (Without Hemorrhage) Other Atopic Dermatitis And Related Conditions Dermatitis Due To Food Taken Internally Unspecified Pruritic Disorder Allergic Urticaria FOR CPT 86003 ONLY This list was compiled from Medicare s Limited Coverage Policies for informational and reference purposes only. For the most cu rrent information please reference Note: If the patient s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.

10 Source: Federal Registry Negotiated Rule-making, November 23, 2001 THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED. Quest , Quest diagnostics , any associated logos, and all associated Quest diagnostics registered or unregistered trademarks are the property of Quest diagnostics . All third party marks - and - are the property of their respective owners. 2015 Quest diagnostics Incorporated. All rights reserved Last Updated: LCD Description: In order for allergy testing to be considered reasonable and necessary by Medicare , antigens must meet all the following criteria - skin testing must be performed based on history and physical exam, proven efficacy as demonstrated through scientifically valid medical studies published in peer-review journal, and exist in the patient's environment with a reasonable probability of exposure.


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