NCDMeister can help you avoid denial of payments for lab tests that don't meet Medicare's definition of medical necessity.
. . . .
To control costs, Medicare and many other insurers deny
payment for tests that they consider "medically unnecessary." Computers
determine if the test you ordered for your patient is "necessary" by comparing the ICD-9
diagnosis code you submitted to a list of approved, payable codes.
These payable codes are listed in a document called the National Coverage Determinations (NCD)
which is published and periodically updated by the Centers
for Medicare and Medicaid Services.
There are more than 15,000 ICD-9 diagnosis codes
out there. For some
tests (like a CBC), thousands of ICD-9 codes may be acceptable and
payable. For other tests, only a handful of ICD-9 codes will be
accepted as payable. For example, a PSA test is payable only if
submitted with one of only 27 ICD-9 diagnosis codes.
These NCD rules often seem arbitary and
puzzling. For example, let's say you have a patient with anemia
who needs a PT and PTT. A prothrombin time (PT) is payable if
associated with any one of seven ICD-9 codes for anemia but a partial
thromboplastin time (PTT) is payable only if associated with just one of
those anemia codes. Double checking that ICD-9 code before
submitting the lab request can be the difference between getting paid
for a lab test and being stuck paying for it yourself.
The NCD payment restrictions are
burdensome. We shouldn't be happy about this. It is yet another bureaucratic hassle
that steals away the time we have with our patients and whittles away at our
We shouldn't be happy about it but we can
minimize its impact. Medicare makes a list of these NCD's freely
available. You can review these
creating NCDMeister, we took all of the useful information from
these pages and reformatted it for easy searching and reference on your
Use NCDMeister to prevent denials of payment by ensuring that
the ICD-9 codes you submit with your lab orders are both appropriate
and accepted as payable by Medicare and other insurers.
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