Medicare Limited Coverage Policies Reference Guide Instructions
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 by State: 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.
Please note that local policies are determined by the performing test location. This is determined by the state in which your performing laboratory resides. The state links below provide a quick reference tool. Please click on the state where your testing is commonly performed. For example: If your office is located in Indiana but testing is sent to Cincinnati, choose Ohio. If your office is located in Indiana, but testing is sent to Auburn Hills Michigan, choose Michigan. If your office is located in Indiana and testing is sent to Indianapolis then select Indiana.