MEDICARE LIMITED COVERAGE GUIDE

The lists of covered diagnosis codes for National and Local Medicare Limited Coverage Tests are provided as a guide for determining if the test is reimbursable by Medicare based on the patient's symptoms or medical condition as indicated by the appropriate ICD-9-CM code. Please note diagnosis codes are required for all Medicare orders to document medical necessity of the testing.

If the diagnosis you provide does not meet the reimbursement rules, or if the frequency limit on test procedures has been exceeded, payment may be denied. In that case, Diagnostic Laboratory of Oklahoma can only seek reimbursement from the patient if they have been notified in advance of the testing that Medicare is likely to deny payment for these services. If the patient chooses to have the test, they must sign an Advance Beneficiary Notice (ABN), confirming their understanding that they will be responsible for payment.

How to use this guide to comply with the Medicare regulations:

1. Determine the diagnosis for the patient.
   
   
2. Write the diagnosis code(s) on the DLO SelecTest requisition form.
   
   
3. To determine if the test(s) ordered are Medicare Limited Coverage tests:
   • Note the "@," "F," and "&" signs on the DLO SelecTest requisition
   • Check the table of contents of this guide
   • If the test is not listed, no further action is required
   
   
4. If the test is Medicare Limited Coverage:
   • Refer to the section for the test and if the patient's diagnosis is listed, no further action is required unless the Limited Coverage Test has frequency limitations.
     Note: The Blood Count section lists the diagnosis codes that DO NOT support medical necessity and are not covered.
   
   
5. If the test has a frequency limitation proceed to #7.
   • Note: the frequency is noted by a (F) next to the test on the DLO SelecTest requisition and is also noted in the guide.
   
   
6. If the patient's diagnosis is not listed, inform the patient that payment for this service is likely to be denied and the reason for the denial:
   • Medical necessity
   • Screening tests
   • Frequency
   • Non-FDA approved tests
     Note: See Non-FDA Approved Test section for list of tests that would fall under this category.
   
   
7. Complete the ABN by filling in the following information:
   • Patient's name
   • Medicare number
   • Check or write in the test
   • The patient must review the ABN and choose option 1 for Yes or option 2 for No
   • Have patient sign and date the ABN
     Note: If the patient wants information on the cost of the test you can fill in the estimated cost.
   
   
8. Please note: If you do not know the ICD-9-CM code for the patient's diagnosis, the ICD-9-CM International Classification of Diseases published by PMIC lists the diagnoses in alphabetical order with corresponding ICD-9-CM codes. Please use the most recently published book. This publication is updated annually.