Commercial Coverage & Coding Guidelines
Insurance plans have specific rules about which laboratory tests they cover and when they will pay for them. Some tests are subject to Limited Coverage Policies (LCPs), which outline the medical conditions, symptoms, or diagnoses that support coverage.
When ordering a test subject to a coverage policy, include the ICD-10-CM code(s) that accurately reflect the patient's symptoms, condition, or reason for testing. The diagnosis information should be supported by the patient's medical record and should explain why the test was ordered.
If the information submitted with the order does not meet the payer's coverage requirements, the test may not be covered and the patient may be responsible for payment.
Commercial Coverage Resources
DLO provides coverage and coding reference guides to help physicians and office staff understand payer requirements and identify commonly used diagnosis codes for certain laboratory tests.
These guides are intended to help your practice submit complete and accurate information with laboratory orders and may help reduce coverage questions, claim denials and administrative follow-up.
Blue Cross and Blue Shield of Oklahoma®
The resources below cover selected laboratory tests and test groups. Select a guide to review applicable coverage limitations and indications for your patient's BCBS home plan.
- Cardiovascular Disease Risk Assessment
- Diabetes Mellitus Testing
- Diagnostic Testing of Iron Homeostasis and Metabolism
- Folate Testing
- General Inflammation Testing
- Medicare Preventive Screening Tool
- Testosterone
- Thyroid Disease Testing
- Vitamin B12
Medicare Coverage & Coding Guidelines
Medicare also has specific coverage policies for certain laboratory tests. These Medicare Limited Coverage Policies (MLCPs) identify the diagnoses and clinical circumstances that support coverage.
When ordering a test subject to an MLCP, include the appropriate ICD-10-CM code that supports the medical necessity of the test. The diagnosis code must accurately reflect the patient's symptoms or condition and be supported by documentation in the medical record.
If the information submitted does not meet Medicare's coverage requirements, payment may be denied and the patient may be responsible for the cost of the test when applicable.
Medicare Coverage & Coding Guides
Use the resources below to review Medicare coverage policies and applicable diagnosis codes for laboratory testing. These guides are intended as a reference for physicians and office staff.
Medicare Coverage & Coding Guide
Medicare Regional Coverage & Coding Guide
These resources are provided for informational purposes. Coverage policies may vary by Medicare Administrative Contractor (MAC) and are subject to change. For the most current coverage requirements, refer to the applicable Medicare contractor and CMS resources.
ICD-10-CM Codes & Medical Necessity
ICD-10-CM codes help document the patient's symptoms, condition or reason for testing. For Medicare laboratory orders, diagnosis information must support the medical necessity of the test and be consistent with the patient's medical record.
Find ICD-10-CM Codes for Medicare Coverage
If the diagnosis information submitted does not support Medicare's coverage requirements, or a frequency limit has been exceeded, payment may be denied.
When Is an ABN Needed?
An Advance Beneficiary Notice of Noncoverage (ABN) helps a Medicare patient understand when Medicare is expected to deny payment for a service that would otherwise generally be covered.
If your practice expects Medicare to deny coverage for a laboratory test because it is not medically necessary or does not meet applicable coverage requirements, an ABN may be required before the test is performed to transfer financial responsibility to the patient.
Learn More About ABNs from CMS
Additional Billing & Coding Resources
For additional information about laboratory billing and coding, visit the Quest Diagnostics Billing & Coding resource.
Visit the CMS Medicare Coverage Database
Medicare Provider Enrollment (PECOS)
Need to enroll in Medicare or update your enrollment information?
The Medicare Provider Enrollment, Chain, and Ownership System (PECOS) is the online system used by healthcare providers and organizations to enroll in Medicare and manage their enrollment information. Providers who order or certify certain Medicare-covered services, including clinical laboratory services, may need to be enrolled in Medicare.
Our PECOS Enrollment page provides information to help you prepare for enrollment, understand the process and access additional resources from the Centers for Medicare & Medicaid Services (CMS).
For direct access to the Medicare enrollment system, visit PECOS.
