Medicare Limited Coverage Policies
Medicare Limited Coverage Policies Reference Guide and Instructions
Medicare has specific coverage policies, known as Limited Coverage Policies (MLCP), for certain laboratory tests. To qualify for coverage under Medicare, tests subject to these policies must meet specific medical necessity criteria. If a test is ordered without a supporting ICD-10 code, it will not meet the medical necessity requirement and, therefore, will not be covered by Medicare.
When ordering these tests, it is essential to submit an Advance Beneficiary Notice signed by your patient. This notice confirms that the patient understands they will be responsible for payment if the test is not covered.
To get started, click the "Medicare Coverage and Coding Guide" button, which will redirect you to the Quest Diagnostics website. From there, select your state from the list or choose your regional Medicare program by clicking the "Medicare Coverage and Coding Guide (Regional)" button.
Medicare Coverage and Coding Guide
Medicare Coverage and Coding Guide (Regional)
Policies in this MLCP Reference Guide apply to testing performed at a Quest Diagnostics facility and apply to Medicare National Coverage Determination Policy and Medicare Local Coverage Determination Policy.
The lists of covered diagnosis codes for National and Local Medicare Limited Coverage Policies 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-CM code. Please note diagnosis codes are required for all Medicare orders to document medical necessity of the testing.
This diagnosis code reference guide is provided as an aid to physicians and office staff in determining when an ABN (Advance Beneficiary Notice) is necessary. Diagnosis codes must be applicable to the patient's symptoms or conditions and must be consistent with documentation in the patient's medical record. Quest Diagnostics does not recommend any diagnosis codes and will only submit diagnosis information provided to us by the ordering physician or his/her designated staff.
If the diagnosis provided does not meet the reimbursement rules, or if the frequency limit on test procedures has been exceeded, payment may be denied. In that case, Quest Diagnostics can seek reimbursement from the patient only when the patient has 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 performed, they must complete an Advance Beneficiary Notice (ABN), confirming their understanding that they will be responsible for payment.
The CPT codes provided are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.
Your cooperation in complying with the Medicare Regulations and related test ordering procedures will eliminate the need for time-consuming follow-up calls to your office.
MLCP Policies for Oklahoma: This list is for informational and reference purposes only. For the most current and accurate information please reference your Medicare Carriers web site by the National Policy Website link
Here is the ICD-10 National Tool for your review.
For more help on billing and coding visit the Quest Diagnostics Billing and Coding site.
Visit the CMS website
