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Medicare Coverage of Laboratory Testing

DISCLAIMER: The policies listed below have been approved and published by either our local Medical Review Board for Local Medicare Coverage policies or by CMS as National Coverage policies regarding laboratory reimbursement. We are sharing these policies with you for your information. As an ordering provider you are required to provide the most appropriate code/text diagnosis for lab tests ordered, however you are not limited to these codes.

When ordering laboratory tests billed to Medicare/Medicaid or other federally-funded programs, the following requirements may apply:

  • Only tests that are medically necessary for the diagnosis or treatment of the patient should be ordered. Medicare does not pay for screening tests, except for certain specifically approved procedures, and may not pay for non-FDA-approved tests or those tests considered experimental.
  • The ordering physician must provide an ICD-10 diagnosis code, not a narrative description, if required by the Medicare Administrative Contractor.
  • Organ- or disease-oriented panels should be billed to Medicare only when every component of the panel is medically necessary.
  • Medicare National Limitation Amounts for CPT codes are available through CMS or its contractors. Medicaid reimbursement will be equal to or less than the amount of Medicare reimbursement.

Current Lab Policies

NCD Section NCD Title
90.1 Pharmacogenomic Testing for Warfarin Response
90.2 Next Generation Sequencing (NGS)
110.23 Stem Cell Transplantation (Formerly 110.8.1)
190.1 Histocompatibility Testing
190.2 Diagnostic Pap Smears
190.3 Cytogenetic Studies
190.5 Sweat Test
190.6 Hair Analysis
190.7 Human Tumor Stem Cell Drug Sensitivity Assays
190.8 Lymphocyte Mitogen Response Assays
190.9 Serologic Testing for Acquired Immunodeficiency Syndrome (AIDS)
190.10 Laboratory Tests - CRD Patients
190.11 Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring for Anticoagulation Management
190.12 Urine Culture, Bacterial
190.13 Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring)
190.14 Human Immunodeficiency Virus (HIV) Testing (Diagnosis)
190.15 Blood Counts
190.16 Partial ThromboplastinTime (PTT)
190.17 Prothrombin Time (PT)
190.18 Serum Iron Studies
190.19 Collagen Crosslinks, any Method
190.20 Blood Glucose Testing
190.21 Glycated Hemoglobin/Glycated Protein
190.22 Thyroid Testing
190.23 Lipid Testing
190.24 Digoxin Therapeutic Drug Assay
190.25 Alpha-fetoprotein
190.26 Carcinoembryonic Antigen
190.27 Human Chorionic Gonadotropin
190.28 Tumor Antigen by Immunoassay - CA 125
190.29 Tumor Antigen by Immunoassay - CA 15-3/CA 27.29
190.30 Tumor Antigen by Immunoassay - CA 19-9
190.31 Prostate Specific Antigen
190.32 Gamma Glutamyl Transferase
190.33 Hepatitis Panel/Acute Hepatitis Panel
190.34 Fecal Occult Blood Test
210.1 Prostate Cancer Screening Tests
210.2 Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer
210.2.1 Screening for Cervical Cancer with Human Papillomavirus (HPV)
210.3 Colorectal Cancer Screening Tests
210.6 Screening for Hepatitis B Virus (HBV) Infection
210.7 Screening for the Human Immunodeficiency Virus (HIV) Infection
210.10 Screening for Sexually Transmitted Infections (STIs) and High-Intensity Behavioral Counseling (HIBC) to Prevent STIs
210.13 Screening for Hepatitis C Virus (HCV) in Adults
LCD Article (Billing & Coding) LCD Title
L37733 A56609 Biomarker Testing (Prior to Initial Biopsy) for Prostate Cancer Diagnosis
L37851 A57059 Biomarker Testing for Neuroendocrine Tumors/Neoplasms
L33573 A56826 B-type Natriuretic Peptide (BNP) Testing
L37606 A56793 Genomic Sequence Analysis Panels in the Treatment of Hematolymphoid Diseases
L37810 A56867 Genomic Sequence Analysis Panels in the Treatment of Solid Organ Neoplasms
L35074 A56767 Heavy Metal Testing
L35000 A56199 Molecular Pathology Procedures
L38371 A57020 Multimarker Serum Tests Related to Ovarian Cancer Testing
L33591 A56844 RAST Type Tests
L36037 A56761 Urine Drug Testing
L37535 A57736 Vitamin D Assay Testing
Billing & Coding A52879 Billing and Coding: Stem Cell Transplantation
Policy A52378 Colorectal Cancer Screening – Medical Policy Article
Policy A52842 Local Coverage Determination (LCD) Reconsideration Process - Medical Policy Article
Policy A56198 New Local Coverage Determination (LCD) Request Process