Client and patient satisfaction is our first priority. We are pleased to provide this guide to assist in determining test coverage under Medicare Local and National Coverage Determination guidelines. Select generic drug name below to identify CPT and ICD-10 codes.
What is a National Coverage Determination (NCD)?
A decision made by The Centers for Medicare and Medicaid Services (CMS) as to whether a service or item may be covered, is known as a national coverage determination (NCD). NCD rulings specify under what clinical circumstances a service is considered reasonable and necessary. An NCD is mandated on a national level and all Medicare contractors are required to follow these rulings.
What is a Local Coverage Determination (LCD)?
A decision made by a Medicare Administrative Contractor (MAC) as to whether a service or item may be covered, is known as a local coverage determination (LCD). LCD rulings specify under what clinical circumstances a service is considered reasonable and necessary. An LCD only applies to the area served by the contractor who made the decision.
What is a Medicare Administrative Contractor (MAC)?
A private health care insurer awarded to a geographic area or “jurisdiction” to manage the policies and medical claims for Medicare beneficiaries. A MAC serves as the primary operational contact between the Medicare program and the health care providers enrolled in the program. They perform many activities including but not limited to: Enrolling providers in Medicare programs, establish LCDs, process Medicare claims, handle redetermination request, and perform audits/reviews of medical records and claims.
What is an Advance Beneficiary Notice (ABN)?
The ABN is a waiver of liability to be used when a provider plans to perform a service that Medicare most likely will determine is not medically necessary. The ABN is signed by the patient and serves as an advance warning to patients that Medicare may not cover the service(s) being provided and that they may be financially responsible for the cost of service(s).
The information referenced in this guide is provided as an aid to physicians and office staff in determining when an ABN (Advance Beneficiary Notice) is necessary. It is the sole responsibility of the ordering physician to determine the appropriate diagnosis code(s) for the specific date of service based on the patient’s signs and symptoms. GeneIQ’s distribution of this information is provided as a customer service and does not suggest nor is it meant to suggest than any of these codes should or should not be used on any given occasion. The codes provided do not represent a complete list. Please refer to an ICD-10 manual for complete listing.
The ICD-10 codes referenced in this guide are listed as medically supportive under CMS Local Coverage Article A58801. Please refer to Local Coverage Determination (LCD) L39063 , Pharmacogenomics Testing for reasonable and necessary requirements.
Please refer to National Coverage Determination (NCD) for Pharmacogenomic Testing for Warfarin Response (90.1) for complete details regarding reasonable and necessary requirements for CYP2C9 and VKORC1. If you are ordering tests for diagnostic reasons that are not covered under Medicare policy, an Advance Beneficiary Notice form is required.
For more information please visit:
National Coverage: CMS.gov
Local Coverage: Novitas-Solutions.com
