Laboratory Medicare & Medicaid Compliance
CaroMont Regional Medical Center Laboratory is dedicated to providing excellent
service while complying with all laws and regulations pertaining to the
delivery of and billing for services to federal and state government programs
such as Medicare and Medicaid.
In an ongoing effort to ensure compliance with Centers for Medicare and
Medicaid Services (CMS), CaroMont Regional Medical Center Laboratory has
developed specific policies and procedures for the prevention of processes
or practices that may result in billing errors or be viewed as fraudulent
It is our goal to ensure that referring physicians and clients are informed
of our policies. Your awareness and understanding of these policies will
assist us in providing efficient, quality patient care while meeting our
responsibilities as a provider of laboratory services.
Medicare is required by federal law to pay only for services it considers
medically necessary to diagnose or treat an illness or injury or to improve
the function of a malformed body member. As a result, Medicare often requires
a specific diagnosis for certain laboratory tests before they will consider
a test medically necessary.
Although physicians may order any tests they feel are necessary to diagnose
and treat a patient appropriately, Medicare will only pay for those that
meet the Medicare definition of medical necessity.
Therefore, all Medicare claims submitted by CaroMont Regional Medical Center
must include complete medical necessity documentation using the ICD-9CM
coding system to be compliant and eligible for reimbursement of services provided.
Physician and Client Responsibilities
It is the responsibility of the ordering physician and laboratory client
to submit all clinically relevant ICD-9 codes for each test on the laboratory
requisition at the time of the test order.
Patients presenting to CaroMont Regional Medical Center outpatient collection
centers with laboratory orders from their physician lacking medical necessity
documentation may experience a delay in services, or will be asked to
sign an Advance Beneficiary Notice (ABN) accepting financial responsibility
for tests which Medicare is likely to deny payment. Therefore, it is important
that the laboratory requisition or physician order provides complete medical
For specimens submitted to our Outreach Services department, the laboratory
requisition accompanying the specimen should include all medical necessity
If medical necessity documentation is not submitted with the requisition
or a valid ABN was not obtained, the charges for these services will be
billed to the referring physician or client office.
Important Points to Remember:
- ICD-9 diagnosis codes are the only acceptable form of medical necessity
- Narrative diagnoses are not acceptable.
- ICD-9 codes submitted must be consistent with documentation in the patient record.
- When choosing an ICD-9 code, always select the code that most accurately
describes the patient’s condition and code to the highest level
- Only physician office or client staff authorized and experienced with coding
should provide ICD-9 codes for laboratory services.
- Providing ICD-9 codes on the Laboratory Requisition will avoid unnecessary
phone calls to physician and client offices as well as delays in service
to patients, to obtain medical necessity documentation.
- An ABN form must be submitted with each lab requisition when a limited-coverage
test is ordered without an ICD-9 code supporting the medical necessity
of the test.
- Laboratory services provided through our Outreach Services department without
medical necessity documentation or a valid ABN will be billed to the referring
physician or client office.
Limited Coverage Tests
Medicare and local Medicare intermediary - Palmetto GBA, have established
national or local medical review policies for specific laboratory tests.
These policies include a list of diagnosis codes indicating what clinical
circumstances justify the medical necessity of an individual test. In
addition, these policies contain information including specific non-covered
diagnosis codes, coding guidelines, reason for denial and frequency limitations.
Click here to view limited coverage tests and Medicare approved ICD-9 diagnosis codes.
To view a coverage policy in its entirety, click on link and follow instructions.
- View AMA License, Click Accept
- Select J11 Part A MAC – NC, SC, VA,WV
- Click Medical Policies
- Select LCDs and NCDs
CaroMont Regional Medical Center Laboratory discourages the use of any
lists, “cheat sheets” or software containing commonly used
ICD-9 codes by physician or client offices, especially for the purpose
of ensuring coverage and reimbursement.
Routine Screening Tests:
Routine screening test(s) are not a Medicare covered service unless specified
in Medicare law. The patient will be financially responsible for payment
of routine screening tests.
Medicare Preventive Services Quick Reference Chart
View PDF Here
Advance Beneficiary Notice (ABN)
The intent and purpose of an ABN is to notify Medicare beneficiaries,
in writing, that a test being ordered for them by their physician may
not be paid for by Medicare. The beneficiary has the opportunity to make
an informed decision about whether or not to have the test and be financially
responsible should Medicare deny payment.
Medicare allows CaroMont Regional Medical Center to bill the patient for
a denied test only if an ABN is completed and signed by the patient prior
to specimen collection.
Routine or blanket ABNs are prohibited by Medicare where there is no reasonable
expectation of non-coverage.
An ABN should be obtained when one or more of the following circumstances exist:
- The diagnosis does not meet medical necessity guidelines.
- The test(s) is for a routine exam or screening.
- The test(s) is for experimental or investigational use.
- The number of times the test(s) can be ordered within a certain time period
is limited by Medicare.
- The test(s) has not been approved by the Food and Drug Administration.
- No diagnosis provided.
The ABN is not valid unless the following information is provided or completed:
- Patient name and Medicare number
- Description or test(s) that may be denied
- Reason why service may be denied
- Estimated test(s) cost – Contact Laboratory Client Services
- Explanation to patient
- Patient reads and checks Option Box
- Patient signature and date
- Provide patient a copy of completed and signed ABN for their records.
Additional ABN forms are available upon request from client services: (704) 834-2881
CaroMont Regional Medical Center Laboratory has clinical consultants available
to answer questions regarding appropriate testing and medical necessity.