Rochester General Health System
Charge Capture and Compliance
Contact Information
| Direct Line: | (585) 922-9350 |
| Fax: | (585) 922-9881 |
| Judy Beeman, MT, Manager: | (585) 922-9882 |
Medical Necessity for Ordering Lab Tests
Any test ordered through the Department of Pathology and Laboratory Medicine must be accompanied by signs and symptoms or a diagnosis indicating the reason for ordering each test. Requisitions must be signed by a provider.
Tips for Requisition Completion
- A diagnosis or signs and symptoms must be placed on the requisition relating to each test ordered. Provide all codes or narrative data that are appropriate for the tests ordered. ALL insurances require diagnostic information on claims for laboratory services.
- ICD-9 codes must contain all digits as specified in the current ICD-9 code book ( i.e., 272 is not a valid code). It must be written with a fourth digit code (Example: 272.0).
- R/O, screening, up or down arrows, +, -, or possible before a narrative diagnosis are not acceptable.
- Medicare does not pay for laboratory testing for screening purposes except as specifically allowed by regulation. Appropriate screening diagnoses must be provided when allowed screening tests are requested.
Thank you for your cooperation and assistance in helping us provide quality laboratory testing to your patients.
Medical Necessity Policies (National or Local Coverage Decisions)
Medicare has established medical necessity criteria for a variety of tests through local or national coverage decisions. This medical necessity criteria may also be followed by private insurers who offer HMO or managed care coverage to medicare-eligible individuals.
If laboratory tests are requested without covered diagnoses on the requisition, the patient will be asked to sign an Advance Beneficiary Notice (ABN), or your office will be contacted for additional diagnostic information.
Click here for the current information on Medicare coverage decisions.
View or print the entire NCD manual
| Medical Necessity Policies | Type |
| Acid Phosphatase (revised October 2008) | LCD |
| Alpha-fetoprotein (revised October 2011) | NCD |
| Amylase (discontinued June 2007) | LCD |
| Beta2 Microglobulin (added November 2008) | LCD |
| Blood Counts (revised October 2011) | NCD |
| Blood Glucose Testing (revised October 2011) | NCD |
| B-type Natriuretic Peptide (BNP) Testing (revised February 2009) | LCD |
| Carcinoembryonic Antigen (revised October 2011) | NCD |
| Chloride, Blood (discontinued June 2007) | LCD |
| Collagen Crosslinks, Any Method (revised October 2011) | NCD |
| Urine Culture (Bacterial Urine Culture) (revised October 2011) | NCD |
| Digoxin Therapeutic Drug Assay (revised October 2011) | NCD |
| Erythrocyte Sedimentation Rate (ESR) (revised October 2009) | LCD |
| Fecal Occult Blood (revised October 2011) | NCD |
| Flow Cytometry (revised October 2010) | LCD |
| Gamma Glutamyl Transferase (revised October 2011) | NCD |
| Glycated Hemoglobin/Glycated Protein (revised October 2011) | NCD |
| Helicobacter Pylori Tests (discontinued June 2007) | LCD |
| Hepatic Function Panel (discontinued December 2011) | LCD |
| Hepatitis Panel (revised October 2011) | NCD |
| High Sensitivity C-Reactive Protein (hsCRP) Testing (discontinued April 2012) | LCD |
| Homocysteine Level, Serum (revised October 2009) | LCD |
| Human Chorionic Gonadotropin (revised October 2011) | NCD |
| Human Immunodeficiency Virus Testing (Diagnosis) (revised October 2011) | NCD |
| Human Immunodeficiency Virus Testing (Prognosis including monitoring) | NCD |
| Ionized Calcium (added November 2008) | LCD |
| Lipid Testing (revised October 2011) | NCD |
| Pap Smear of the Cervical or Vaginal Mucosa (discontinued June 2007) | LCD |
| Parathormone (Parathyroid Hormone, PTH) (discontinued April 2012) | LCD |
| Partial Thromboplastin Time (PTT) (revised October 2011) | NCD |
| Phosphorus inorganic (phosphate) (discontinued June 2007) | LCD |
| Potassium (Serum) Levels (discontinued June 2007) | LCD |
| Prostate Specific Antigen (revised March 2009) | LCD |
| Prothrombin Time (PT) (revised October 2011) | NCD |
| Qualitative Drug Screen (revised August 2011) | LCD |
| RAST Type Tests (revised October 2009) | LCD |
| Reticulocyte Counts (discontinued June 2007) | LCD |
| Serum Iron Studies (revised October 2011) | NCD |
| Serum Magnesium (discontinued May 2012) | LCD |
|
Syphilis Tests (revised January 2010) |
LCD |
| Thyroid Testing (revised October 2011) | NCD |
| Tumor Antigen by Immunoassay CA 19-9 (revised October 2011) | NCD |
| Tumor Antigen by Immunoassay CA15-3/CA 27.29 (revised October 2011) | NCD |
| Tumor Antigen by Immunoassay CA125 (revised October 2011) | NCD |
| Urinalysis (discontinued June 2007) | LCD |
| Viral Hepatitis Serology Tests (discontinued December 2011) | LCD |
| Vitamin D25-OH (added September 2009) | LCD |
