Medicare Coverage Articles

The term "article" is used to describe any bulletin article, website article, educational handout or any other non-LCD document intended for public release that contains coverage/coding statements or medical review related billing or claims considerations.

Medicare contractors post articles into the Medicare Coverage Database (MCD). Articles address local coverage, coding or medical review related billing and claims considerations, and may include any newly developed educational materials, coding instructions or clarification of existing medical review related billing or claims policy.

View coverage information on topics found outside NCDs and LCDs. As articles are updated in the MCD, they will be published as webpages here as well. Watch the below list continue to expand as updates are made.

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Topic Brief Description
Abbreviated Daytime Sleep Study (e.g. PAP-NAP) [PDF] View coverage and billing requirements for Abbreviated Daytime Sleep Studies
Additional Information Required for Coverage and Pricing for Category III CPT® Codes [PDF] View coverage and document requirements for Additional Information Required for Coverage and Pricing for Category III CPT® Codes Coverage.
Billing Medicare for the SphenoCath and Other Similar Devices [PDF] View coverage and billing requirements for Billing Medicare for the SphenoCath® Device Coverage.

Chemotherapy Administration [PDF]

View coverage and billing requirements for Chemotherapy Administration Coverage.

Coding Guidelines: Noninvasive Peripheral Venous Studies [PDF] View coding guidelines for Noninvasive Peripheral Venous Studies
Coenzyme Q10 (Q10) Coding and Billing Guideline [PDF] View Coding and Billing Guidelines for Coenzyme (CoQ10)
Dropless Cataract Surgery [PDF] View coverage and billing information for Dropless Cataract Surgery.
Flow Cytometry Coverage Clarification [PDF] View billing clarification for Flow Cytometry coverage.
Fracture Care Coding for Physicians Many times the initial treating physician does not provide all of the follow-up care after surgery. View examples of acceptable ways to bill for definitive or restorative treatment of a fracture.
HemoDialysis Frequency [PDF] View billing, documentation, and coding requirements for coverage and payment of additional hemodialysis sessions.
High Compression Bandage System Clarification [PDF] View coverage and billing requirements for High Compression Bandage System Clarification Coverage.
Home PT/INR Monitoring Billing and Coding [PDF] View coding and billing guidance related to the NCD for Home Prothrombin Time/International Normalized Ration Monitoring for Anticoagulation Monitoring.
Hydration Services [PDF] View coverage and billing requirements for Hydration Services Coverage.
Implantable Infusion Pumps for Chronic Pain [PDF] View information regarding implanted Infusion Pumps for Chronic pain and Compounded Drugs
Incident To Clarification for OPPS and CAH Outpatient [PDF] View key points related to "incident to" regulations in an outpatient hospital setting
Intraocular Bevacizumab Coding/Billing Guidelines [PDF] Coverage and billing requirements for off-label use of bevacizumab for intravitreal injection.
Investigational Device Exemptions (IDE) - IDE Documentation Requirements for Studies with an FDA Approval dated January 01, 2015 or Later [PDF] View details regarding Medicare reimbursement for some investigational devices and related services. Coverage is contingent on the Medicare contractor's approval of the application for reimbursement.
IUD (Hormone-Eluting) for Endometrial Hyperplasia - CPT 58999 [PDF] View appropriate ICD-10 CM diagnoses for endometrial hyperplasia and use of CPT 58999.
JW Modifier Billing Guidelines [PDF] View coverage and billing requirements for JW Modifier Billing Guidelines article
Lymphedema Decongestive Treatment [PDF] View coverage and billing requirements for Lymphedema Decongestive Treatment Coverage.
Medical Necessity of Therapy Services [PDF] View coverage and billing requirements for Medical Necessity of Therapy Services Coverage.
MolDX: Abbott RealTime IDH2 testing for Acute Myeloid Leukemia (AML) Billing and Coding Guidelines [PDF] View coverage and billing requirements for Abbott RealTime IDH2 testing for Acute Myeloid Leukemia (AML)
MolDX: Afirma™ Assay by Veracyte Billing and Coding Guidelines [PDF] View coverage and billing requirements for Afirma Assay by Veracyte.
MolDX: Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing Billing and Coding Guidelines [PDF] View coverage and billing requirements for Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy (ARVD/C) Testing
MolDX: Aspartoacyclase 2 Deficiency (ASPA) Testing Billing and Coding Guidelines [PDF] View coverage and billing requirements for Aspartoacyclase 2 Deficiency (ASPA) Testing
MolDX: ATP7B Gene Tests Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: ATP7B Gene Tests Billing and Coding Guidelines.
MolDX: Avise PG Assay Billing and Coding Guidelines [PDF] View coverage and billing requirements for Avise PG Assay
MolDX: BCKDHB Gene Test Billing and Coding Guidelines [PDF] View coverage and billing requirements for BCKDHB Gene Testing.
MolDX: BCR-ABL Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: BCR-ABL.
MolDX: Billing and Coding for Lynch Syndrome Testing Services [PDF] View coverage and billing requirements for Lynch Syndrome Testing.
MolDX: bioTheranostics Cancer TYPE ID® Billing and Coding Guidelines [PDF] View coverage and billing requirements for the bioTheranostics Cancer TYPE ID® assay.
MolDX: Bladder Tumor Marker FISH Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: Bladder Tumor Marker FISH Billing and Coding Guidelines.
MolDX: BLM Gene Analysis Billing and Coding Guidelines [PDF] View coverage and billing requirements for BLM Gene Analysis.
MolDX: BluePrint® Billing and Coding Guidelines [PDF] View coverage and billing requirements for BluePrint®.
MolDX: CDH1 Genetic Testing Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX CDH1 Genetic Testing
MolDX: CFTR Gene Analysis Coding and Billing Guidelines [PDF] Genetic testing for cystic fibrosis (CF) transmembrane conductance regulator (CFTR) is typically performed to screen adults with a positive family history of CF. Therefore, the MolDX team has determined that CFTR gene testing to identify parents at risk is not a Medicare benefit and is a statutorily excluded test.
MolDX: CHD7 Gene Analysis Coding and Billing Guidelines [PDF] MolDX has determined that SMPD1 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single disease testing, Noridian will also deny panels of tests that include a SMPD1 gene test as a statutorily excluded service.
MolDX: ENG and ACVRL1 Gene Tests Billing and Coding Guidelines [PDF] View coverage and billing requirements for ENG and ACVRL1 Gene Tests.
MolDX: FDA Approved CLL Companion Diagnostic Test Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: FDA Approved CLL Companion Diagnostic Testing
MolDX: Fragile X Billing and Coding Guidelines Update [PDF] View coverage and billing requirements for Fragile X.
MolDX: GBA Genetic Testing Billing and Coding Guidelines [PDF] View coverage and billing requirements for Abbreviated Daytime Sleep Studies
MolDX: HBB Gene Tests Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: HBB Gene Tests.
MolDX: HEXA Gene Analysis Billing and Coding Guidelines [PDF] View coverage and billing requirements for HEXA Gene Analysis 
MolDX: IKBKAP Genetic Testing Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: IKBKAP Genetic Testing.
MolDX: Know error Billing and Coding Guidelines Update [PDF] View updated coverage and billing requirements for MolDX: Know error.
MolDX: L1CAM Gene Sequencing Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: L1CAM Gene Sequencing.
MolDX: MammaPrint Billing and Coding Guidelines [PDF] View coverage and billing requirements for MammaPrint
MolDX: MCOLN1 Genetic Testing Billing and Coding Guidelines [PDF] There is insufficient evidence to support the required clinical utility for the established Medicare benefit category.
MolDX: Mitochondrial Nuclear Gene Tests Billing and Coding Guidelines [PDF] View updated coverage and billing requirements for MolDX: Mitochondrial Nuclear Gene Tests.
MolDX: MMACHC Test Billing and Coding Guidelines [PDF] View billing and coding guidelines for MolDX: MMACHC testing
MolDX: myPap Billing and Coding Guidelines Update [PDF] View updated coverage and billing requirements for MolDX: myPap Tests.
MolDX: Myriad's BRACAnalysis CDx™ Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: Myriad's BRACAnalysis CDx™ .
MolDX: Next Generation Sequencing Billing and Coding Guidelines [PDF] View updated coverage and billing requirements for MolDX: Next Generation Sequence.
MolDX: NSD1 Gene Tests Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: NSD1 Gene Tests.
MolDX: OncoCee Billing and Coding Guidelines [PDF] View updated coverage and billing requirements for MolDX: OncoCee.
MolDX: PAX6 Gene Sequencing Billing and Coding Guidelines [PDF] View billing and coding guidelines for MolDX: PAX6 Gene Sequencing
MolDX: PIK3CA Gene Tests Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: PIK3CA Gene Tests.
MolDX: PreDx® Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: PreDx®.
MolDX: PTCH1 Gene Testing Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: PTCH1 Gene Testing.
MolDX: Quidel Solana Strep Complete Assay and Quidel Lyra Direct Strep Assay Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: Quidel Solana Strep Complete Assay and Quidel Lyra Direct Strep Assays.
MolDx: ResponseDX Tissue of Origin® Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDx: ResponseDX Tissue of Origin®.
MolDX: RPS19 Gene Tests Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: RPS19 Gene Tests.
MolDX: SETP9 Gene Test Billing and Coding Guidelines [PDF] View billing and coding guidelines for MolDX: SETP9 Gene Tests
MolDX: SLCO1B1 Genotype Billing and Coding Guidelines [PDF] To date, there is insufficient evidence to support the required clinical utility for the established Medicare benefit category. Therefore, the SLCO1B1 genotype test is a statutorily excluded service.
MolDX: SMPD1 Genetic Testing Billing and Coding [PDF] MolDX has determined that SMPD1 genetic testing is not a Medicare benefit and is a statutorily excluded service. In addition to single disease testing, Noridian will also deny panels of tests that include a SMPD1 gene test as a statutorily excluded service.
MolDX: STAT3 Gene Testing Billing and Coding Guidelines [PDF] There is insufficient evidence to support the required clinical utility for the established Medicare benefit category.
MolDX: SULT4A1 Genetic Testing Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: SULT4A1 Genetic Testing.
MolDX: TERC Gene Tests Billing and Coding Guidelines [PDF] View coverage and billing requirements for MolDX: TERC Gene Tests.
MolDX: TP53 Gene Test Billing and Coding Guidelines [PDF] View coverage and billing requirements for the TP53 Gene Test
MolDX: UGT1A1 Gene Analysis Billing and Coding Guidelines [PDF] There is insufficient evidence to support the required clinical utility for the established Medicare benefit category.
MolDX: VEGFR2 Tests Coding and Billing Guidelines [PDF] View coding and billing guidelines for MolDX: VEGFR2
Outpatient Therapy Biofeedback Training [PDF] View Medicare coverage and billing of Outpatient Therapy Biofeedback Training. 
Parenteral Iron Administration Coverage in Non-Dialysis Usage [PDF] View coverage description for the Parenteral Iron Administration Coverage in Non-Dialysis Usage.
Patients Supplied Donated Free-of-Charge Drug [PDF] View coverage and billing requirements for Patients Supplied Donated Free-of-Charge Drug.
Pegfilgrastim (Neulasta) J2505 [PDF] View coverage and medical necessity guidelines for Pegfilgrastim (Neulasta) J2505 Coverage.
Peripheral Nerve Blocks Non-covered for the Treatment of Diabetic Peripheral Neuropathic Pain [PDF] View non-coverage description for Peripheral Nerve Blocks Non-covered for the Treatment of Diabetic Peripheral Neuropathic Pain.
Physician Supervision of Dialysis for Acute Kidney Injury [PDF] View coverage and billing requirements for Physician Supervision of Dialysis for Acute Kidney Injury Coverage.
Piriformis Injections [PDF] View coverage and billing requirements for Piriformis Injections Coverage.
Posterior Tibial Nerve Stimulation Coverage [PDF] View coverage and billing requirements for Posterior Tibial nerve Stimulation Coverage.
Reporting a Non-Covered Test Performed in Preparation for a Non-Covered Procedure [PDF] When a diagnostic test is necessary for the performance of a non-covered service, that test typically may not be covered. Noridian wishes to remind providers to appropriately report this as a non-covered test, by submitting the code with a GY modifier.
Routine Dental Services [PDF] ICD-10-CM codes that are considered routine dental services and are non covered.
Sclerosing of Varicose Veins [PDF] View information regarding incorrect coding for CPT 37241 for varicose vein ablation.
Sipuleucel-T (Provenge®) - Coverage Criteria for Prostate Cancer - Clarification [PDF] View clarification for coverage criteria for Prostate Cancer
Sleep Lab Credentialing: Polysomnography and Other Sleep Studies [PDF] View Sleep Lab Credentialing for Polysomnography and Other Sleep Studies
Special Stains and Immunohistochemistry (IHC) Indications for Gastric Pathology [PDF] View coverage and billing requirements for Special Stains and Immunohistochemistry (IHC) Indications for Gastric Pathology.
Spinal Fusion Services: Documentation Requirements [PDF] View clarification of medical necessity and documentation requirements.
Testopel Coverage [PDF] View coverage guidelines for Testopel pellets.
Therapeutic Apheresis for Familial Hypercholesterolemia [PDF] View coverage information for therapeutic apheresis in the treatment of refractory familial hypercholesterolemia.
Therapy Driving Evaluations [PDF] View Medicare coverage and billing guide for Therapy Driving Evaluations.
Therapy Evaluation and Assessment Services [PDF] View coverage and billing requirements for Therapy Evaluation and Assessment Services Coverage.
Therapy Evaluation Coding [PDF] View coverage and billing requirements for Therapy Evaluation Coding Coverage.
Therapy Students and Aides [PDF] View coverage and billing requirements for Therapy Students and Aides Coverage.
Topical HBO and Physician Related Service Billing and Coding Guidelines [PDF] View coverage and billing requirements for Topical HBO and Physician Related Service Billing and Coding Guidelines
Treatment with Yttrium-90 Microspheres View coverage and billing requirements for Yttrium-90 Microspheres.
Waiver of Face-to-Face Visit for Home Dialysis Patients – Coding and Billing [PDF] View coding guidelines to request waiver with 52 modifier to the appropriate monthly capitation CPT codes 90963-90966.
Wound Care & Debridement-Provided by a Therapist, Physician, NPP or as Incident-to Services [PDF] View coverage and billing requirements for Wound Care & Debridement – Provided by a Therapist, Physician, NPP or as Incident-to Services Coverage.
Zika Virus Testing by PCR and ELISA Methods [PDF] View Zika Virus billing and coverage information

 

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Last Updated Aug 13, 2018