Medical Necessity

Medical Necessity

CMS Limitations Guides for medical necessity under ICD-10 are now available. For more information, please visit the CMS website.

Unacceptable Principal Diagnosis Codes

Situation

Currently we are receiving denials for primary diagnosis codes that were previously allowed to be listed as the primary/principal diagnosis code. 

Family history of codes (Z90.0-Z84.89)

Long-term use of codes (Z79.02-Z79.84)

Background

Center for Medicare and Medicaid Services (CMS) publishes quarterly updates to their list of Unacceptable Principal Diagnosis codes. These quarterly changes have caused some codes that were previously acceptable to be listed alone as primary diagnosis codes to deny. 

Assessment

Denials are being reviewed for any additional changes and additional education will follow if needed.

Recommendation

Providers and staff should refrain from using diagnosis codes that listed above.

CMS Limitations Guides (ICD-10)

Click on the links below to open the PDF in a new window. You can also right click and save the file to your computer. 

Cardiovascular Services 


Laboratory Services (Updated February 2017)

Download the complete Laboratory Services Guide or follow the links to the individual sections below.

NON-COVERED ICD-10-CM CODES FOR ALL LAB NCDS (PDF)
(NCD 190.12) Urine Culture, Bacterial (PDF)
(NCD 190.13) Human Immunodeficiency Virus (HIV) Testing (PDF)
(NCD 190.14) Human Immunodeficiency Virus (HIV) Testing (Diagnosis) (PDF)
(NCD 190.15) Blood Counts – NON-COVERED DIAGNOSES (PDF)
(NCD 190.16) Partial Thromboplastin Time (PTT) (PDF)
(NCD 190.17) Prothrombin Time (PT) (PDF)
(NCD 190.18) Serum Iron Studies (PDF)
(NCD 190.19) Collagen Crosslinks, Any Method (PDF)
(NCD 190.20) Blood Glucose Testing (PDF)
(NCD 190.21) Glycated Hemoglobin-Glycated Protein (PDF)
(NCD 190.22) Thyroid Testing (PDF)
(NCD 190.23) Lipids Testing (PDF)
(NCD 190.24) Digoxin Therapeutic Drug Assay (PDF)
(NCD 190.25) Alpha-fetoprotein (PDF)
(NCD 190.26) Carcinoembryonic Antigen (PDF)
(NCD 190.27) Human Chorionic Gonadotropin (PDF)
(NCD 190.28) Tumor Antigen by Immunoassay CA 125 (PDF)
(NCD 190.29) Tumor Antigen by Immunoassay CA 15-3_CA 27.29 (PDF)
(NCD 190.30) Tumor Antigen by Immunoassay CA 19-9 (PDF)
(NCD 190.31) Prostate Specific Antigen (PDF)
(NCD 190.32) Gamma Glutamyl Transferase (PDF)
(NCD 190.33) Hepatitis Panel-Acute Hepatitis Panel (PDF)
(NCD 190.34) Fecal Occult Blood Test (PDF)
(L34645) Drug Testing (PDF)
(L34658) Vitamin D Assay Testing (PDF)

Mammography & Bone Mass Measurement

(L34639) Bone Mass Measurement (PDF)
Screening Mammography (PDF)
(NCD 220.4) Diagnostic Mammography (PDF)

Radiology Services

(L34438) Dysphagia (PDF)
(L35121) Coronary Computed Tomography Angiography (CCTA) (PDF)
(L35751) Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies (PDF)
(L35753) Non-Invasive Cerebrovascular Studies (PDF)
(L35755) Non-Invasive Abdominal/Visceral Vascular Studies (PDF)
(L35761) Non-Invasive Peripheral Arterial Vascular Studies (PDF)
Ultrasound Screening for Abdominal Aortic Aneurysm (AAA) (PDF)