Laboratory Medical Necessity Checking Guide

Medicare will only pay for laboratory tests deemed medically necessary based on the diagnostic information provided by the referring physician from the patient's medical record. Colaborate developed this Laboratory Medical Necessity Checking Guide in a user-friendly spiral book for quick and easy physician in-office medical necessity checking of test orders.

Our standard guide includes the Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) tests and their related ICD-9 diagnosis listed in both alpha and numeric order, making it easy for users to quickly check whether:

a patient’s symptomatic diagnosis meets the Medicare conditions for payment; or
the patient should sign an Advanced Beneficiary Notice (ABN), and be responsible for payment if denied by Medicare.

Additionally, some Medicare Carriers and Fiscal Intermediaries (FIs) have identified other tests called local coverage determination (LCD) tests that require a medically justifiable ICD-9 code or signed ABN for payment. For orders of 125 or more, the FI or Carrier LCDs for your region can be added upon request for a small additional fee.

This guide also includes test and coding detail, frequency screening criteria for the national limited coverage tests (which always requires the patient to sign an ABN), and the new ABN format (which became a requirement March 1, 2009).

As referring physicians and laboratories work together to provide this necessary information, there are many user benefits:

Beneficiaries receive the requested testing without confusion or unexpected additional costs.
Physicians receive high-quality, hassle-free and uninterrupted laboratory services.
Laboratories receive payment for the services rendered.
Both the physician and laboratory avoid the regulatory risk of providing free laboratory services.

This guide is a must for physicians performing or referring Medicare laboratory testing, as well as every sales, patient registration, client service, and billing representative supporting a laboratory outreach program. It is our hope that users will find this guide to be a valuable tool in ensuring compliance and meeting service expectations of all parties involved.

Also upon request for orders of 125 or more, your laboratory’s "logo" can be printed on the cover at no additional charge, so that they may be used as a marketing piece to promote your laboratories outreach services.