BELLIN HEALTH

Laboratory

National Coverage Determinations (NCDs)

Local Coverage Determinations (LCDs)

Index

Americhoice Reimbursement Policies

CMS NCD Website

NGS Medicare Part A LCD Website

WPS Medicare Part B LCD Website

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

A CPT Code
Acid Phosphatase; Prostatic (NGS) 84066
Acid Phosphatase; Total (NGS) 84060
Allergen Specific Ig E; Each Allergen (RAST) (AMERICHOICE) 86003
Allergen Specific Ig E; Each Allergen (RAST) (NGS) 86003
Allergen Specific Ig E; Multiallergen (RAST) (NGS) 86005
Allergen Specific Ig G; Each Allergen (RAST) (NGS) 86001
Alpha-fetoprotein; Serum (NCD) 82105
Apolipoprotein; Each (NGS) 82172
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B
B Cells; Total Count (NGS) 86355
Beta-2 Microglobulin (NGS) 82232
Blood Smear Exam: Manual: Without Differential Parameters (NCD) 85008
B-type Natriuretic Peptide (BNP) (NGS) 83880
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C
CA 27.29 (NCD) 86300
CA 15-3 (NCD) 86300
CA 19-9 (NCD) 86301
CA 125 (NCD) 86304
CBC with Differential; Automated (NCD) 85025
CEA(NCD) 82378
Cholesterol; HDL (NCD) 83718
Cholesterol; HDL (NGS) 83718
Cholesterol; LDL; Direct (NCD) 83721
Cholesterol; LDL; Direct (NGS) 83721
Cholesterol; Total (NCD) 82465
Cholesterol; Total (NGS) 82465
Cholesterol; VLDL; Direct (NGS) 83719
Culture; Urine; Identification (NCD) 87088
Culture; Urine; Quantitative (NCD) 87086
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D
Dark Field Examination, Any Source (IE: Penile, Vaginal, Oral, Skin); Includes Specimen Collection (NGS) 87164
Dark Field Examination, Any Source (IE: Penile, Vaginal, Oral, Skin); Without Specimen Collection (NGS) 87166
Differential; Manual; Includes RBC Morphology and PLT Estimate (NCD) 85004 85007
Digoxin(NCD) 80162
Drug Screen; Confirmation (NGS) 80102
Drug Screen; Qualitative; Multiple Drug Class Method; Each Procedure (NGS) 80100
DrugScreen; Qualitative; Single Drug Class Method; Each Procedure (NGS) 80101
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E
Erythrocyte Sedimentation Rate; Automated (ESR) (NGS) 85652
Erythrocyte Sedimentation Rate; Non-automated (ESR) (NGS) 85651
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F
Ferritin(NCD) 82728
Flow Cytometry; Cell Cycle or DNA Analysis (NGS) 88182
Flow Cytometry; Cell Surface, Cytoplasmic, or Nuclear Marker, Technical Component Only; Each Additional Marker (NGS) 88185
Flow Cytometry; Cell Surface, Cytoplasmic, or Nuclear Marker, Technical Component Only; First Marker (NGS) 88184
Flow Cytometry, Interpretation; 2 to 8 Markers (NGS) 88187
Flow Cytometry, Interpretation; 9 to15 Markers (NGS) 88188
Flow Cytometry, Interpretation; 16 or more Markers (NGS) 88189
Fructosamine (Glycated Protein) (NCD) 82985
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G
Gamma Glutamyl Transferase (GGT) (NCD) 82977
Glucose(NCD) 82947, 82948, 82962
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H
HCG; Quantitative (NCD) 84702
Hematocrit(NCD) 85014
Hematocrit: Spun (NCD) 85013
Hemoccult; Diagnostic (NCD) 82272
Hemoccult; Screening (NCD) G032882270
Hemoglobin(NCD) 85018
Hemoglobin A1C (NCD) 83036
Hemogram (Cell Profile) (NCD) 85027
Hepatic Function Panel (NGS) 80076

Hepatitis A Antibody (HAAb); IgM (AMERICHOICE)

86709

HepatitisA Antibody (HAAb); IgM (NGS)

86709

HepatitisA Antibody (HAAb); Total (AMERICHOICE)

86708

Hepatitis A Antibody (HAAb); Total (NGS)

86708

Hepatitis B Core Antibody (HBcAb); IgM (AMERICHOICE)

86705

Hepatitis B Core Antibody (HBcAb); IgM (NGS)

86705
Hepatitis B Core Antibody (HBcAb); Total (AMERICHOICE) 86704
Hepatitis B Core Antibody (HBcAb); Total (NGS) 86704

Hepatitis B Surface Antibody (HBsAb) (AMERICHOICE)

86706

Hepatitis B Surface Antibody (HBsAb) (NGS)

86706

Hepatitis B Surface Antigen (HBsAg) (AMERICHOICE)

87340, 83741

Hepatitis B Surface Antigen (HBsAg) (NGS)

87340, 83741

Hepatitis Be Antigen (HBeAg) (AMERICHOICE)

87350

Hepatitis Be Antigen (HBeAg) (NGS)

87350

Hepatitis Be Antibody (HBeAb) (AMERICHOICE)

86707

Hepatitis Be Antibody (HBeAb) (NGS)

86707

Hepatitis C Antibody (AMERICHOICE)

86803

Hepatitis C Antibody (NGS)

86803

Hepatitis C Antibody; Confirmatory Test (IE: Immunoblot) (AMERICHOICE)

86804

Hepatitis C Antibody; Confirmatory Test (IE: Immunoblot) (NGS)

86804
Hepatitis Delta Agent Antibody (NGS) 86692

Hepatitis Delta Agent Antigen (AMERICHOICE)

87380

Hepatitis Delta Agent Antigen (NGS)

87380
Hepatitis Panel; Acute (NCD) 80074
High Sensitivity C-Reactive Protein (hsCRP) (NGS) 86141
HIV Testing; Diagnosis (NCD) 86689, 86701, 86702, 86703, 87390, 87391, 87534, 87535, 87537, 87538
HIV Testing; Prognosis and Monitoring (NCD) 87536, 87539
Homocysteine Level, Serum (NGS) 83090
Human Papillomavirus (HPV) Testing (NGS) 87621
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I
Immunohistochemistry (Including Tissue Immunoperoxidase); Each Antibody (NGS) 88342
Ionized Calcium (NGS) 82330
Iron (NCD) 83540
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J
K
L
Lipid Panel (NCD) 80061
Lipid Panel (NGS) 80061
Lipoprotein; Electrophoretic Separation (NCD) 83700
Lipoprotein; Electrophoretic Separation (NGS) 83700
Lipoprotein; High Resolution Fractionation (NCD) 83701
Lipoprotein; High Resolution Fractionation (NGS) 83701
Lipoprotein; Quantitation of Lipoprotein Particle Numbers and Lipoprotein Subclasses (NCD) 83704
Lipoprotein; Quantitation of Lipoprotein Particle Numbers and Lipoprotein Subclasses (NGS) 83704
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M
Magnesium (NGS) 83735
Mononuclear Cell Antigen; Quantitative; Not Otherwise Specified; Each Antigen (NGS) 86356
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N
Natural Killer (NK) Cells; Total Count (NGS) 86357
NTx-Telopeptide (Collagen Crosslinks) (NCD) 82523
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O
P
PAP Smear; Diagnostic (WPS) 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154, 88164, 88165, 88166, 88167, 88174, 88175
PAP Smear; Screening (NCD) G0101, G0123, G0124, G0141, G0143, G0144, G0145, G0147, G0148, P3000, P3001, Q0091
Parathormone (PTH, Immunoreactive PTH, Parathyroid Hormone) (NGS) 83970
Partial Thromboplastin Time (PTT) (NCD) 85730
Platelet Count (PLT); Automated 85049
Platelet Count (PLT); Manual (NCD) 85032
Platelets, Irradiated: Each Unit (NGS) P9032
Platelets, Leukocytes Reduced, Irradiated; Each Unit (NGS) P9033
Platelets, Pheresis, Irradiated; Each Unit (NGS) P9036
Platelets, Pheresis, Leukocytes Reduced, CMV-Negative, Irradiated: Each Unit (NGS) P9053
Platelets, Pheresis, Leukocytes Reduced, Irradiated; Each Unit (NGS) P9037
Protime (PT) (NCD) 85610
PSA; Complexed (Direct Measurement) (NGS) 84152
PSA; Free (NGS) 84154
PSA; Total; Diagnostic (NCD) 84153
PSA; Total; Diagnostic (NGS) 84153
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Q
R
Red Blood Cells, Frozen/Deglycerolized/Washed, Leukocytes Reduced, Irradiated; Each Unit (NGS) P9057
Red Blood Cells, Irradiated; Each Unit (NGS) P9038
Red Blood Cells, Leukocytes Reduced, CMV-Negative, Irradiated; Each Unit (NGS) P9058
Red Blood Cells, Leukocytes Reduced, Irradiated; Each Unit (NGS) P9040
Red Blood Count (RBC); Manual (NCD) 85032
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S
Sensitivity Testing; Cultures (NCD) 87184, 87186
Stem Cells (IE: CD34); Total Count (NGS) 86367
Syphilis Test (VDRL, RPR, ART); Qualitative (NGS) 86592
Syphilis Test (VDRL, RPR, ART); Quantitative (NGS) 86593
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T
T Cells; Absolute CD4 and CD8 Count; Including Ratio (NGS) 86360
T Cells; Absolute CD4 Count (NGS) 86361
T Cells; Total Count (NGS) 86359
T4; Free (NCD) 84439
T4; Total (NCD) 84436
Thyroid Hormone (T3 or T4) Uptake or Thyroid Hormone Binding Ratio (NCD) 84479
TIBC (NCD) 83550
Transferrin (NCD) 84466
TreponemaPallidum Antibody (FTA-ABS); Confirmatory Test (NGS) 86781
TreponemaPallidum Antigen; Immuno fluorescent Technique (NGS) 87285
Triglyceride (NCD) 84478
Triglyceride (NGS) 84478
TSH (NCD) 84443
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U
V
Vitamin D Total (NGS) 82306
W
WhiteBlood Count (WBC); Automated (NCD) 85048
WhiteBlood Count (WBC); Manual (NCD) 85032
WholeBlood, Leukocytes Reduced, Irradiated; Each Unit (NGS) P9056
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X
Y
Z
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Please Note:

  1. Policies labeled as NCD (National Coverage Determinations) apply to all testing, regardless of whether the test is submitted to WPS or NGS, for payment. All NCDs, indexed above, link directly to the CMS (Centers for Medicare and Medicaid Services) Website.
  2. Policies labeled as WPS (Wisconsin Physician Service) apply to only those tests submitted to WPS Medicare Part B, for payment. (This would include those tests performed on-site within the Bellin Medical Group Laboratories). The WPS LCDs, indexed above, are individually linked to the WPS Website.
  3. Policies labeled as NGS (National Government Services) apply to only those tests submitted to NGS, for payment. (This would include those tests performed at either the Bellin Hospital Main Laboratory or the Oconto Hospital and Medical Center Laboratory). The NGS LCDs, indexed above, are individually linked to the NGS Website.
  4. Policies labeled as AMERICHOICE (United Health MA HMO) apply to only those tests submitted to AMERICHOICE for payment, either by the Bellin Medical Laboratories, Bellin Hospital Main Laboratory, or the Oconto Hospital and Medical Center Laboratory). The AMERICHOICE LCDs, indexed above, are individually linked to the AMERICHOICE Website.
  5. All NCDs also apply to Medicare Part C (Humana Gold, Medicare Complete Essential, Unicare, etc).
  6. As of 07-22-09, NGS does not have a published LCD for Diagnostic Pap Smears. At this time, it is suggested to follow the WPS LCD.
  7. Also, as of 07-22-09, active WPS LCDs not referenced in this Index include: ALRG-001, PATH-001, PATH-002, PATH-016, PATH-026, PATH-027, PATH-028, and PATH-031.
  8. Information regarding the Medicare Diabetes Screening Benefit can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0660.pdf
  9. Information regarding the Medicare Cardiovascular (Lipoprotein Panel) Screening Benefit can be found at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM3411.pdf

Updated 04-09-2011

For comments or questions concerning this web page, please contact Brenda Koppa at blkopp@bellin.org