MLN Matters Number: MM6084
Related Change Request (CR) #: 6084
Related CR Release Date: June 6, 2008
Effective Date: July 1, 2008
Related CR Transmittal #: R1531CP
Implementation Date: July 7, 2008

Changes to the Laboratory National Coverage Determination (NCD) Edit Software for July 2008

Provider Types Affected
Clinical diagnostic laboratories billing Medicare contractors (carriers, fiscal intermediaries (FI) and/or Part A/B Medicare administrative contractors (AB MAC))

Provider Action Needed
This article is based on Change Request (CR) 6084 which announces the changes that will be included in the July 2008 quarterly release of the edit module for clinical diagnostic laboratory services. The last quarterly release of the edit module was issued in April 2007. CR 6084 incorporates all changes from April 2007 to the present and has no other changes.

Background
The National Coverage Determinations (NCD) for clinical diagnostic laboratory services were developed by the laboratory negotiated rulemaking committee and published in a final rule on November 23, 2001. Nationally uniform software was developed and incorporated in the shared systems so that laboratory claims subject to one of the 23 NCDs were processed uniformly throughout the nation effective January 1, 2003.

In accordance with the Medicare Claims Processing Manual (Chapter 16, Section 120.2; see http://www.cms.hhs.gov/manuals/downloads/clm104c16.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site) the laboratory edit module is updated quarterly as necessary to reflect ministerial coding updates and substantive changes to the NCDs developed through the NCD process. These changes are a result of coding analysis decisions developed under the procedures for maintenance of codes in the negotiated NCDs and biannual updates of the ICD-9-CM codes.

CR 6084 announces changes to the laboratory edit module for changes in laboratory NCD code lists for July 2008 as described below. These changes become effective for services furnished on or after July 1, 2008. Contractors are not required to search their files to adjust affected claims between the July 1, 2007, and the July 1, 2008, quarterly clinical lab edit module updates.

CR 6084 reports the following changes effective July 1, 2008:

For HIV Testing:

• Add ICD-9-CM codes 079.83 and 288.66 to the list of ICD-9-CM codes covered by Medicare for the HIV Testing (190.14) NCD.
• Modify the descriptor for Current Procedural Terminology (CPT code 86701 in the HIV Testing (190.14) NCD to read “Antibody; HIV-1.”
• Modify the descriptor for CPT code 86702 in the HIV Testing (190.14) NCD to read “Antibody; HIV-2.”
• Modify the descriptor for CPT code 86703 in the HIV Testing (190.14) NCD to read “Antibody; HIV-1 and HIV-2, single assay.”

For Blood Counts:

• Add ICD-9-CM codes 388.45, 389.05, 389.06, 389.13, 389.17, 389.20, 389.21, 389.22, V25.04, V26.41, V26.49, V26.81, V26.89, V49.85 and V72.12 to the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD.
• Delete ICD-9-CM codes 389.2, V26.4 and V26.8 from the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD.
• Modify the descriptor for ICD-9-CM code 389.14 to read “Central hearing loss” in the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD;
• Modify the descriptor for ICD-9-CM code 389.18 to read “Sensorineural hearing loss, bilateral” in the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD; and
• Modify the descriptor for ICD-9-CM code 389.7 to read “Deaf, non-speaking, not elsewhere classifiable” from the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts (190.15) NCD.

For Prothrombin Time:

• Add ICD-9-CM codes 415.12, 789.51, 789.59, V12.53, and V12.54 to the list of ICD-9-CM codes covered by Medicare for the Prothrombin Time (190.17) NCD.
• Delete ICD-9-CM code 789.5 from the list of ICD-9-CM codes covered by Medicare for the Prothrombin Time (190.17) NCD.

For Serum Iron Studies:

• Add ICD-9-CM codes 233.30, 233.31, 233.32, and 233.39 to the list of ICD-9-CM codes covered by Medicare for the Serum Iron Studies (190.18) NCD.
• Delete ICD-9-CM code 233.3 from the list of ICD-9-CM codes covered by Medicare for the Serum Iron Studies (190.18) NCD.

For Glycated Hemoglobin/Glycated Protein:

• Add ICD-9-CM codes 258.01, 258.02 and 258.03 to the list of ICD-9-CM codes covered by Medicare for the Glycated Hemoglobin/Glycated Protein (190.21) NCD.
• Delete ICD-9-CM code 258.0 from the list of ICD-9-CM codes covered by Medicare for Glycated Hemoglobin/Glycated Protein (190.21) NCD.

For Thyroid Testing:

• Add ICD-9-CM codes 255.41, 255.42, 258.01, 258.02, 258.03, 787.20, 787.21, 787.22, 787.23, 787.24, 787.29, 789.51 and 789.59 to the list of ICD-9-CM codes covered by Medicare for the Thyroid Testing (190.22) NCD.
• Delete ICD-9-CM codes 255.4, 258.0, 787.2 and 789.5 from the list of ICD-9-CM codes covered by Medicare for the Thyroid Testing (190.22) NCD.

For Gamma Glutamyl Transferase:

• Add ICD-9-CM codes 359.21, 359.22, 359.23, 359.24 and 359.29 to the list of ICD-9-CM codes covered by Medicare for the Gamma Glutamyl Transferase (190.32) NCD.
• Delete ICD-9-CM code 359.2 from the list of ICD-9-CM codes covered by Medicare for the Gamma Glutamyl Transferase (190.32) NCD.

For Hepatitis Panel/Acute Hepatitis Panel:

• Delete ICD-9-CM code 999.3 from the list of ICD-9-CM codes covered by Medicare for the Hepatitis Panel/Acute Hepatitis Panel (190.33) NCD.

For Fecal Occult Blood Test:

• Add ICD-9-CM codes 569.43, 787.20, 787.21, 787.22, 787.23, 787.24, 787.29, 789.51 and 789.59 to the list of ICD-9-CM codes covered by Medicare for the Fecal Occult Blood Test (190.34) NCD.
• Delete ICD-9-CM codes 787.2 and 789.5 from the list of ICD-9-CM codes covered by Medicare for the Fecal Occult Blood Test (190.34) NCD.
• Modify the descriptor for ICD-9-CM code 005.1 in the Fecal Occult Blood Test (190.34) NCD to read “Botulism food poisoning.”
• Modify the descriptor for CPT code 82272 in the Fecal Occult Blood Test (190.34) NCD to read “Blood, occult, by peroxidase activity (e.g., guaiac), qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening.”

Additional Information
The official instruction, CR 6084, issued to your carrier, FI, and A/B MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1531CP.pdf on the CMS Web site.

If you have any questions, please contact your carrier, FI, or A/B MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.

Disclaimer This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.