License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

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The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

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Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
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March 18, 2014

Laboratory Services: Medical Necessity and National Coverage Determinations (NCDs)

The Centers for Medicare & Medicaid Services (CMS) created 23 National Coverage Determinations (NCDs) for specific clinical laboratory tests, including the tests listed above. Whereas most NCDs describe covered indications and limitations in narrative form, laboratory NCDs list specific ICD-10 codes that fall into 3 categories:

Covered ICD-10 codes
Non-covered ICD-10 codes
Codes that do not support medical necessity

Before Submitting Claims

Refer to the ICD-10 code lists for the applicable NCD.
- Download the ICD-10 code lists for each NCD from the CMS website: under Downloads, select Lab Code List.
If the patient's condition is on the non-covered list or list of codes that do not support medical necessity, you may consider asking the patient to sign an Advance Beneficiary Notice of Noncoverage (ABN).
- Refer to the CGS Modifier Tool, HCPCS modifier GA, for more information, and to the CMS resources in the Reference section of this article for further guidance on issuing these notices.
Remember to double-check medical records to ensure that valid orders and signatures are present.

Current list of Lab NCDs: Alphabetical

NCD#	Title
190.25	Alpha-fetoprotein
190.15	Blood Counts
190.20	Blood Glucose Testing
190.26	Carcinoembryonic Antigen
190.19	Collagen Crosslinks, Any Method
190.24	Digoxin Therapeutic Drug Assay
190.34	Fecal Occult Blood Test
190.32	Gamma Glutamyl Transferase
190.21	Glycated Hemoglobin/Glycated Protein
190.33	Hepatitis Panel/Acute Hepatitis Panel
190.27	Human Chorionic Gonadotropin
190.14	Human Immunodeficiency Virus (HIV) Testing (Diagnosis)
190.13	Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring)
190.23	Lipid Testing
190.16	Partial Thromboplastin Time (PTT)
190.31	Prostate Specific Antigen
190.17	Prothrombin Time (PT)
190.18	Serum Iron Studies
190.22	Thyroid Testing
190.28	Tumor Antigen by Immunoassay (CA 125)
190.29	Tumor Antigen by Immunoassay (CA 15-3/CA 27.29)
190.30	Tumor Antigen by Immunoassay (CA 19-9)
190.12	Urine Culture, Bacterial

Reference:

CMS Lab NCD Web page
CMS Beneficiary Notices Initiative (BNI) Web page
Additional guidance: Medicare Claims Processing Manual (Pub. 100-04), chapter 30, section 50
- Prohibition on issuing "routine notices" and "blanket notices": section 40.2.2
- Beneficiary's refusal to sign ABN: section 50.6
- Guidance for repetitive services: section 50.8
CMS Medicare Learning Network publication, "Medicare Advance Written Notices of Non-coverage"

Reviewed: 12.15.22