24-433 New Claims Edit for Non-Covered Lab Services
Date: 05/08/24
Verify lab services when billed with only a non-covered diagnosis code to avoid claims denials
Effective July 12, 2024, Health Net is implementing an edit to deny diagnostic lab testing services when billed with only a diagnosis code that is not covered under National Coverage Determinations (NCD) guidelines to ensure regulatory requirements are met. The claims edit will apply to both professional and outpatient facility claims.
Currently, we are seeing a number of diagnostic lab services claims being billed with only a non-covered diagnosis that goes against NCD guidelines. As a reminder, the Centers for Medicare & Medicaid Services (CMS) documents specific coding and coverage requirements in NCD, Local Coverage Determinations and other sources. These coding guidelines also apply to claims billed under the Commercial line of business. If CMS requires that a certain procedure code, value code, provider specialty, condition code, bill type, etc. be used, these requirements must be followed.
Laboratory services: Claims are paid based on NCD policies
A claim submitted for payment of a diagnostic lab test without a specific diagnosis code that is allowed based on NCD policies will result in denial of payment for these services. Claims denials are based on CMS guidelines as such:
- There are certain diagnosis codes that are never covered by Medicare for a diagnostic lab testing service when given as the primary reason for the test.
- Per CMS, a diagnostic lab test is performed to rule out or confirm a suspected diagnosis because the patient has a sign and/or symptoms (Medicare Claims Processing Manual, Chapter 16 Laboratory Services, Section 120.1).
- Medicare does not cover diagnostic lab test done on patients with no personal disease history and with no disease signs or symptoms.
- If the patient's condition is on the non-covered list, you may consider asking the patient to sign an Advance Beneficiary Notice of Noncoverage (ABN).
NCD lab edits
The lists below are codes that are never covered by Medicare for a diagnostic lab testing service. This is not an all-inclusive list. To access the complete and up-to-date list, refer to the CMS website under Lab Code List.
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NCD Lab policy | Non-covered | Edit description |
|---|---|---|
190.12 | 87086, 87088 | Deny when billed with a diagnosis that is not covered per NCD 190.12 |
190.13 | 87536, 87539 | Deny when billed with a diagnosis that is not covered per NCD 190.13 |
190.14 | 86689, 86701, 86702, 86703, 87390, 87391, 87534, 87535, 87537, 87538 | Deny when billed with a diagnosis that is not covered per NCD 190.14 |
190.15 | 85004, 85007, 85008, 85013, 85014, 85018, 85025, 85027, 85032, 85048, 85049 | Deny when billed with a diagnosis that is not covered per NCD 190.15 |
190.16 | 85730 | Deny when billed with a diagnosis that is not covered per NCD 190.16 |
190.17 | 85610 | Deny when billed with a diagnosis that is not covered per NCD 190.17 |
190.18 | 82728, 83540, 83550, 84466 | Deny when billed with a diagnosis that is not covered per NCD 190.18 |
190.19 | 82523 | Deny when billed with a diagnosis that is not covered per NCD 190.19 |
190.20 | 82947, 82948,82962 | Deny when billed with a diagnosis that is not covered per NCD 190.20 |
190.21 | 82985, 83036 | Deny when billed with a diagnosis that is not covered per NCD 190.21 |
190.22 | 84436, 84439, 84443, 84479 | Deny when billed with a diagnosis that is not covered per NCD 190.22 |
190.23 | 80061, 82465, 83700, 83701, 83704, 83718, 83721, 84478 | Deny when billed with a diagnosis that is not covered per NCD 190.23 |
190.24 | 80162 | Deny when billed with a diagnosis that is not covered per NCD 190.24 |
190.25 | 82105 | Deny when billed with a diagnosis that is not covered per NCD 190.25 |
190.26 | 82378 | Deny when billed with a diagnosis that is not covered per NCD 190.26 |
190.27 | 84702 | Deny when billed with a diagnosis that is not covered per NCD 190.27 |
190.28 | 86304 | Deny when billed with a diagnosis that is not covered per NCD 190.28 |
190.29 | 86300 | Deny when billed with a diagnosis that is not covered per NCD 190.29 |
190.30 | 86301 | Deny when billed with a diagnosis that is not covered per NCD 190.30 |
190.31 | 84153 | Deny when billed with a diagnosis that is not covered per NCD 190.31 |
190.32 | 82977 | Deny when billed with a diagnosis that is not covered per NCD 190.32 |
190.33 | 80074 | Deny when billed with a diagnosis that is not covered per NCD 190.33 |
190.34 | 82272 | Deny when billed with a diagnosis that is not covered per NCD 190.34 |
Additional information
If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center at:
Line of business | Phone number | |
|---|---|---|
IFP Ambetter PPO | ||
IFP Ambetter HMO | ||
Health Net Employer Group HMO, POS & PPO | ||
Medicare (Individual & Employer Group) | ||
Behavioral Health Providers | N/A |
This information applies to Physicians, Hospitals, Ancillary Providers, and Behavioral Health Providers.