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Medicare & Insurance Guidelines
Medicare & Insurance Guidelines

Medicare & Insurance Information


CODING GUIDELINES:

  • All claims must be submitted with an ICD diagnosis code.
  • The appropriate ICD diagnosis code must be linked to the procedure that is ordered or performed by the physician. 

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.  

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 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.