Medicare requires the ordering provider to supply diagnostic codes of why lab work is being performed. Medicare generally does not pay for “routine lab work” and the patient will be responsible for payment in these scenarios. To request a Medical Necessity booklet please call (800) 633-4227 or (877) 486-2048.
If the diagnostic codes provided do not justify medical necessity or if a certain test has frequency limitations, we may ask for the patient to sign an Advanced Beneficiary Notice that states we are uncertain if Medicare will pay for this and the patient may be responsible for payment. A valid ABN list the test(s), gives a reason why the test(s) may be denied, and has the patients’ signature that if the test is denied, the patient will be fully responsible for payment.
If Medicare denies a test as not medically necessary or routine, PLA will verify that an ABN was signed and bill the patient. If an ABN was not signed, and client collected the specimen(s) in their office, PLA will have no recourse except to bill the requesting physician for the test(s) ordered, since failure to do so could invoke the anti-kickback statutes that pertain to physician/laboratory relationships.
If an ICD10 code or diagnosis is not written on the requisition or submitted with an electronic order, PLA will contact the client by fax to obtain an ICD10 code. If the ICD10 code given does not justify medical necessity, PLA will attempt twice to notify the client.
We urge the patient to call their physician if there is any question on the diagnostic code that is being submitted. Your physician will need to contact PLA if a change in diagnosis codes is needed.