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Medicare & Insurance Guidelines
Medicare & Insurance Guidelines

Medicare & Insurance Information


CODING GUIDELINES:

  • All claims must be submitted with one of the covered ICD-9 diagnosis codes as listed in this model Brad and Nicole.jpgpolicy.
  • The appropriate ICD-9 diagnosis code must be linked to the procedure that is ordered or performed by the physician.
  • ICD-9 code V82.9 (special screening of other conditions, unspecified condition) or comparable narratives should be used to indicate screening tests performed in the absence of a specific sign, symptom, or complaint. Use of the V82.9 code or comparable narrative will result in the denial of claims as non-covered screening services.

PROVIDER-BASED CLINIC BILLING
If you are a provider-based clinic Physicians Laboratory is required to bill the technical component (TC) of the Pap tests on all Medicare and Medicare HMO patients back to your facility.  If you are part of the TC grandfather clause we can bill the TC of the surgical specimens to Medicare if you so desire.  The memo below is intended to help clarify which CPT codes to use when billing Paps to those insurances.

Memo for Provider-Based Clinics Regarding Billing

Title XVIII of the Social Security Act, Section 1862 (a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary.

The mere fact of linking a covered diagnosis to a covered procedure does not support the medical necessity of the procedure. Medical necessity for the testing must be present and documented in the patient's medical/clinical record.



DOCUMENTATION REQUIREMENTS:

Documentation supporting the medical necessity of these tests, such as ICD-9 diagnosis codes, must be submitted on the claims. Failure to do so may result in denial of claim(s). The ordering physician should retain in the patient's medical record, history and physical examination notes documenting evaluation and management of one of the medically covered condition/diagnoses, with relevant clinical sign/symptoms or abnormal laboratory results, appropriate to one of the covered indications. The patient's clinical record should further indicate changes/alterations in medications prescribed or the treatment of these conditions. There must be a physician's order for each test documented in the patient's medical/clinical record.