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Adding further confusion to NCD 190.3, National Government Services today issued a News Alert instructing providers they have looked at the list of Discretionary Covered Indications of NCD 190.3 and decided that 48 out of the 661 codes contained in the Discretionary list of covered codes will be covered for Cytogenetic Procedures within the NGS Jurisdiction. Rather than using the well tested method of listing covered diagnosis requirements in an LCD with notice and comment periods, effective dates, appeals processes, etc... we'll just put it an email newsletter. I'm sure the NGS customer service representatives will be well educated on this. :-| CodeMap is working on adding these codes to datafiles for customers billing to NGS.
Q: Can you please review NCD 210.6, specifically codes 86706 and 87340. Our clearinghouse is stating these CPT®’s need to go through Medical Necessity, but they are not in our Codemap file.
A: 210.6 is a screening benefit which requires specific diagnosis codes only if these tests are run for the purpose of the screening benefit. There are no diagnosis code restrictions at the NCD or your LCD level for Hepatitis B diagnostic tests.
CMS created code G0499 to be used for the screening benefit but only for non-pregnant beneficiaries. For pregnant beneficiaries, you would have to use one of the diagnostic procedure codes (86706, 87340) and a combination of 2 diagnosis codes including a supervision of pregnancy dx. Bottom line, if we put these requirements in the file, all diagnostic Hepatitis B procedures would be required to meet these narrow requirements for a pregnant medicare patient or generate an ABN. In other words, every claim for the diagnostic Hep B tests would require an ABN which is probably something you do not want to do.
Q: Our Indiana MAC has a policy L36805 which is not appearing in our CodeMap Data Files. Why not?
A: L36805 has no associated diagnosis codes for the CPT codes contained in the policy. This is typical of a contractor Article although it is currently marked as an LCD. Without a list of diagnosis codes, there are no codes specified for Medical Necessity checking.