Lab testing, Medicare

In general under Medicare:

  • Not covered: Routine screening labs
  • Covered: Preventive and diagnostic screening labs

However, unless you order labs according to Centers for Medicare and Medicaid Services (CMS) rules, labs may be denied when they should actually be covered.

Diagnosis codes are required on the order

All the rules for notices of non-coverage apply to non-covered laboratory services. Here is some additional guidance:

The physician order must include a diagnosis/diagnoses on the order

  • Orders must have diagnoses before the laboratory may provide any laboratory service.
  • Laboratories may not populate the order with a generic diagnosis code if none is on the order.

Laboratories should advise members when their lab orders are incomplete (i.e., missing diagnoses) and refer them to their ordering physicians to have the orders redone.

Billing for non-covered labs

Laboratories may offer to contact Priority Health Medicare Customer Service at 888.389.6648 to request a pre-service determination, or tell the member to call, if the complete order has either a non-covered lab or some labs not covered.

If ordered and billed incorrectly, claims will be denied as provider liability unless appropriate notice is given to the patient and the lab bills with the required GA modifier.

Routine screening labs

Laboratory tests done for routine screening purposes when the lab is ordered as part of a supplemental comprehensive physical are not covered by Medicare Part C/Medicare Advantage plans.

If the patient has a condition that is being treated, follow Medicare National Coverage Determination (NCD) 190 rules for laboratory and pathology labs, billing the appropriate diagnosis code for the specific service.

Preventive screening labs

Specific labs identified in the Medicare publication Quick Reference Information: Preventive Services are preventive only. These are covered at $0 cost-share for both Original Medicare beneficiaries and Priority Health Medicare Advantage plan members when ordered as required by Medicare billing rules. 

See codes and more details under Medicare preventive services.

Diagnostic screening labs

Medicare and Priority Health cover diagnostic labs when associated with treating a medical condition such as hyperlipidemia or vitamin D deficiency. Such labs are subject to the rules under either NDC 190 or LCDs.

Screening-specific guidance

PSA tests

  • Preventive: Covered once a year for beneficiaries 50 and older. Use G0103 with diagnosis code Z12.5. If you use any other code combination, you are ordering a diagnostic PSA. See more details under PSA tests.
  • Diagnostic: Order under the diagnostic lab code 84153 if your patient has a condition such as BPH, etc.

Lipid panels

  • Preventive: Only covered once every 5 years for asymptomatic patients.
  • Diagnostic: Covered for patients with cardiovascular conditions. Order following the rules of National Coverage Determination 190.23.

Vitamin D