Medicare

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).

Learn About PECOS Enrollment

For direct access to the Medicare enrollment system, visit PECOS.

Medicare Provider Enrollment (PECOS)

The Provider Enrollment, Chain, and Ownership System (PECOS) is the online Medicare enrollment system used by healthcare providers and organizations to enroll in Medicare and manage their enrollment information.

If you order or certify Medicare-covered services, including clinical laboratory services, you must meet Medicare's ordering and certifying requirements. To qualify as an ordering and certifying provider, you must have an individual National Provider Identifier (NPI), be enrolled in Medicare in an approved or opt-out status, and be an eligible provider type.

Already enrolled in Medicare? If you are currently enrolled as a Medicare Part B provider, you can already order and certify Medicare-covered services and do not need to enroll again solely for that purpose.

Access PECOS

Before You Enroll

Plan ahead before starting your PECOS application. The information you need will vary based on your provider type and enrollment situation, and PECOS will guide you through the information that applies to your application.

You may need information such as:

• Individual NPI
• Identity & Access Management (I&A) user ID and password
• Personal information, including name, date of birth and Social Security number
• Education and professional training information
• Professional license information, including license number, issue date, expiration date and issuing state
• Certification information, when applicable
• Specialty and secondary specialty information
• Drug Enforcement Administration (DEA) information, when applicable
• Information about final adverse actions, when applicable
• Practice location and additional practice information
• Electronic Funds Transfer (EFT) information, when applicable

Tip: Review CMS's current enrollment resources before you begin. PECOS is designed to show you the information relevant to your specific application.

View CMS Enrollment Requirements

How to Enroll

PECOS makes it possible to complete your Medicare enrollment application online. The system allows you to enter and review your information, upload supporting documentation, electronically sign and submit your application.

1. Access PECOS. Sign in or create the credentials needed to access the Medicare enrollment system.
2. Prepare your information. Review CMS's enrollment requirements and gather the information and documentation needed for your provider type.
3. Complete your application. Enter and review the information requested by PECOS.
4. Upload supporting documentation. Provide any documentation required for your application.
5. Sign and submit electronically. Review your application, electronically sign and submit it through PECOS.

Important: PECOS is paperless for electronic enrollment applications, so you generally do not need to print and mail a Certification Statement or other documents after submitting electronically. If you use a paper enrollment application instead, follow CMS's instructions for signing and submitting the paper application to your Medicare Administrative Contractor (MAC).

Start or Manage Your PECOS Enrollment

Need Help With PECOS?

CMS provides technical assistance for providers who have trouble accessing or navigating PECOS. For questions about your enrollment eligibility, application requirements or enrollment status, contact your Medicare Administrative Contractor (MAC).

CMS External User Services (EUS) Help Desk

• Phone: 1-866-484-8049
• Email: EUS_Support@cms.hhs.gov
• Hours: Monday–Friday, 7 a.m.–7 p.m. ET

EUS can assist with technical issues such as accessing PECOS, navigating the system, system-generated errors and account access. For questions about the substance of your Medicare enrollment application, contact your Medicare Administrative Contractor.

Visit the CMS EUS Help Desk

Additional Medicare Enrollment Resources

CMS provides additional resources for Medicare enrollment, including enrollment applications, revalidation, ordering and certifying requirements, Medicare Administrative Contractor information and PECOS tutorials.

CMS Medicare Provider Enrollment

CMS Ordering & Certifying Requirements

Manage Your Medicare Enrollment

DLO provides this information as a resource for healthcare providers. Medicare enrollment requirements and procedures may change. For the most current requirements, always refer to CMS and your Medicare Administrative Contractor.