LCD ID Number: L34247 Status: R- Retired
LCD Title: Pulmonary Function Testing
Geographic Jurisdiction: American Samoa, Guam, Hawaii, Northern Mariana Islands Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
Revision Effective Date:
Revision End Date: 11/04/2023
CMS National Coverage Policy:
Title XVIII of the Social Security Act (SSA), §1862(a)(1)(A), states that no Medicare payment shall be made for items or services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
Title XVIII of the Social Security Act, §1862(a)(7) and 42 Code of Federal Regulations (CFR), §411.15, exclude routine physical examinations.
Title XVIII of the Social Security Act, §1833(e), prohibits Medicare payment for any claim lacking the necessary documentation to process the claim.
42 CFR §410.32 and §410.33, indicate that diagnostic tests are payable only when ordered by the physician who is treating the beneficiary for a specific medical problem and who uses the results in such treatment.
CMS Manual System, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, §126.96.36.199, Third-party Additional Documentation Request.
CMS Manual System, Publication 100-08 , Medicare Program Integrity Manual, Chapter 15, Enrollment, §§15.5.19 - 188.8.131.52 Independent Diagnostic Testing Facilities Standards. See also 42 CFR 410.33.
CMS Manual System, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, §§60 and 80, indicate that the technical component of diagnostic tests are not covered as "incident-to" physician healthcare services, but under a distinct coverage category and subject to supervision levels found in the Physician Fee Schedule database. See also 42 CFR §§410.32 and 410.33.
Ruling of the Administrator 95-1 (HCFA Ruling 95-1), binding on providers, contractors, and Administrative Law Judges, states that by virtue of their licensure and practice, providers are responsible for knowing norms of community practice.
CMS Manual System, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, §184.108.40.206., Diagnosis Code Requirement.
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