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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:

  1. 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.
  2. The ordering physician must provide an ICD-10 diagnosis code, not a narrative description, if required by the Medicare Administrative Contractor.
  3. Organ- or disease-oriented panels should be billed to Medicare only when every component of the panel is medically necessary.
  4. 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