Medicare Test Frequency Limitations

Medicare Test Frequency Limitations

Test Name	HNL Test Code	CPT	Frequency Limitations Descriptions	Needs Lmn Or Supporting Dx?	Medicare Policy	Where to find policy
LIPID PANEL	LIPAN	80061	Z13.6 Will cover once every 5 years	SUPPORTING DX	Medicare Preventative Schedule	Cardiovascular Disease Screening Tests
LIPID PANEL	LIPAN	80061	Inability to stabilize lipid-lowering drug dosing (Z79.899) Adverse reaction to lipid-lowering drug (Z79.899) Pancreatitis (B25.2, K85.00, K85.01, K85.02, K85.10, K85.11, K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, K85.80, K85.81, K85.82, K85.90, K85.91, K85.92, K86.0, K86.1) Monitoring of acitretin (i.e., Soriatane) therapy (Z79.899) will cover no more than every two months	SUPPORTING DX	L35099	Lipids Testing
VITAMIN C - ASSAY OF ASCORBIC ACID	VITC	82180	Up to 1 times per year without diagnosis limitations applied at this time	LMN NEEDED	L34914	Assays of Vitamins and Metabolic Function
OCCULT BLOOD - screening	OCBSC	82270	Once every 12 months for patients age 50 & over	LMN NEEDED	A52378	Colorectal Cancer Screening
OCCULT BLOOD - diagnostic	OCCLT	82272	In patients who are taking non-steroidal anti-inflammatory drugs and have a history of gastrointestinal bleeding but no other signs, symptoms, or complaints associated with gastrointestinal blood loss, testing for occult blood may generally be appropriate no more than once every three months.	BOTH	190.34	Fecal Occult Blood Test
VITAMIN D; 25 HYDROXY	VTD	82306	Up to 3 times per year with supporting dx	BOTH	L34914	Assays of Vitamins and Metabolic Function
CARCINOEMBRYONIC ANTIGEN (CEA)	CEA	82378	Serum CEA determinations are generally not indicated more frequently than once per chemotherapy treatment cycle for patients with metastatic solid tumors which express CEA or every two months post-surgical treatment for patients who have had colorectal carcinoma. However, it may be proper to order the test more frequently in certain situations, for example, when there has been a significant change from prior CEA level or a significant change in patient status which could reflect disease progression or recurrence. Testing with a diagnosis of an in situ carcinoma is not reasonably done more frequently than once, unless the result is abnormal, in which case the test may be repeated once.	BOTH	190.26	Carcinoembryonic Antigen
ASSAY OF CARNITINE	CARN & UCAR	82379	Up to 3 times per year with supporting dx	BOTH	L34914	Assays of Vitamins and Metabolic Function
CHOLESTEROL	CHOL	82465	Z13.6 Will cover once every 5 years	SUPPORTING DX	Medicare Preventative Schedule	Cardiovascular Disease Screening Tests
CHOLESTEROL	CHOL	82465	Inability to stabilize lipid-lowering drug dosing (Z79.899) Adverse reaction to lipid-lowering drug (Z79.899) Pancreatitis (B25.2, K85.00, K85.01, K85.02, K85.10, K85.11, K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, K85.80, K85.81, K85.82, K85.90, K85.91, K85.92, K86.0, K86.1) Monitoring of acitretin (i.e., Soriatane) therapy (Z79.899) will cover no more than every two months	SUPPORTING DX	L35099	Lipids Testing
COLLAGEN NTx X-LINK	CNTXL	82523	Because of significant specimen to specimen collagen crosslink physiologic variability (15-20%), current recommendations for appropriate utilization include: one or two base-line assays from specified urine collections on separate days; followed by a repeat assay about 3 months after starting anti-resorptive therapy; followed by a repeat assay in 12 months after the 3-month assay; and thereafter not more than annually, unless there is a change in therapy in which circumstance an additional test may be indicated 3 months after the initiation of new therapy.	BOTH	190.19	Collagen Crosslinks, Any Method
VITAMIN B12	VB12, ANCP2, VB12STAT	82607	Up to 2 times per year with supporting dx	BOTH	L34914	Assays of Vitamins and Metabolic Function
VITAMIN D; 1, 25 DIHYDROXY	VD1	82652	Up to 2 times per year with supporting dx	BOTH	L34914	Assays of Vitamins and Metabolic Function
ASSAY OF FOLIC ACID SERUM	FOLATE, ANCP2	82746	Up to 3 times per year with supporting dx	BOTH	L34914	Assays of Vitamins and Metabolic Function
REAGENT STRIP/BLOOD GLUCOSE	HNL DOES NOT PERFORM	82948	Once per month unless with supporting dx	SUPPORTING DX	L35099	Lipids Testing
GLUCOSE BLOOD TEST	HNL DOES NOT PERFORM	82962	Once per month unless with supporting dx	SUPPORTING DX	L35099	Lipids Testing
GAMMA GT	GGT	82977	When used to assess liver dysfunction secondary to existing non-hepatobiliary disease with no change in signs, symptoms, or treatment, it is generally not necessary to repeat a GGT determination after a normal result has been obtained unless new indications are present. If the GGT is the only “liver” enzyme abnormally high, it is generally not necessary to pursue further evaluation for liver disease for this specific indication. When used to determine if other abnormal enzyme tests reflect liver abnormality rather than other tissue, it generally is not necessary to repeat a GGT more than one time per week.	BOTH	190.32	Gamma Glutamyl Transferase
FRUCTOSAMINE	FRUC	82985	Once per month	LMN	L35099	Lipids Testing
HEMOGLOBIN A1c	HA1CG	83036	Once per month	LMN	L35099	Lipids Testing
ASSAY OF HOMOCYSTEINE	HCYS, CVCP3, HCCP1	83090	Up to 1 times per year with supporting dx	BOTH	L34914	Assays of Vitamins and Metabolic Function
ASSAY LIPOPROTEIN PLA2	MCHG83698	83698	Up to 1 times per year with supporting dx	BOTH	L34914	Assays of Vitamins and Metabolic Function
HDL CHOLESTEROL,DIR	HDLD	83718	Z13.6 Will cover once every 5 years	SUPPORTING DX	Medicare Preventative Schedule	Cardiovascular Disease Screening Tests
			Inability to stabilize lipid-lowering drug dosing (Z79.899) Adverse reaction to lipid-lowering drug (Z79.899) Pancreatitis (B25.2, K85.00, K85.01, K85.02, K85.10, K85.11, K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, K85.80, K85.81, K85.82, K85.90, K85.91, K85.92, K86.0, K86.1) Monitoring of acitretin (i.e., Soriatane) therapy (Z79.899) will cover no more than every two months	SUPPORTING DX	L35099	Lipids Testing
LDL CHOLESTEROL, DIRECT	LDL	83721	No more than every 2 months unless with supporting dx	SUPPORTING DX	L35099	Lipids Testing
PSA,TOTAL, PROSTATE SPECIFIC ANTIGEN - diagnostic	PSA	84153	Generally, for patients with lower urinary tract signs or symptoms, the test is performed only once per year unless there is a change in the patient’s medical condition. Testing with a diagnosis of in situ carcinoma is not reasonably done more frequently than once, unless the result is abnormal, in which case the test may be repeated once.	BOTH	210.1	Prostate Cancer Screening Tests
ASSAY OF VITAMIN B6	VTB6	84207	Up to 1 times per year with supporting dx	BOTH	L34914	Assays of Vitamins and Metabolic Function
ASSAY OF VITAMIN B2	VITB2	84252	Up to 1 times per year without diagnosis limitations applied at this time	LMN	L34914	Assays of Vitamins and Metabolic Function
ASSAY OF VITAMIN B1	VB1, WBVB1	84425	Up to 1 times per year without diagnosis limitations applied at this time	LMN	L34914	Assays of Vitamins and Metabolic Function
T4, THYROXINE; TOTAL	TH7	84436	Up to 4 times per year for most patients,  unless with supporting dx	SUPPORTING DX	L35099	Lipids Testing
T4 FREE, THYROXINE; FREE	FT4	84439	Up to 4 times per year for most patients,  unless with supporting dx	SUPPORTING DX	L35099	Lipids Testing
THYROID STIMULATING HORMONE (TSH)	TSH	84443	Up to 4 times per year for most patients,  unless with supporting dx	SUPPORTING DX	L35099	Lipids Testing
ASSAY OF VITAMIN E	VAECP, VITAE	84446	Up to 1 times per year without diagnosis limitations applied at this time	LMN	L34914	Assays of Vitamins and Metabolic Function
TRIGLYCERIDE	TRIG	84478	Z13.6 Will cover once every 5 years	SUPPORTING DX	Medicare Preventative Schedule	Cardiovascular Disease Screening Tests
			Inability to stabilize lipid-lowering drug dosing (Z79.899) Adverse reaction to lipid-lowering drug (Z79.899) Pancreatitis (B25.2, K85.00, K85.01, K85.02, K85.10, K85.11, K85.12, K85.20, K85.21, K85.22, K85.30, K85.31, K85.32, K85.80, K85.81, K85.82, K85.90, K85.91, K85.92, K86.0, K86.1) Monitoring of acitretin (i.e., Soriatane) therapy (Z79.899) will cover no more than every two months	SUPPORTING DX	L35099	Lipids Testing
T3, Uptake	T3U	84479	Up to 4 times per year for most patients,  unless with supporting dx	SUPPORTING DX	L35099	Lipids Testing
ASSAY OF VITAMIN A	VAECP, VITAB	84590	Up to 1 times per year without diagnosis limitations applied at this time	LMN	L34914	Assays of Vitamins and Metabolic Function
ASSAY OF VITAMIN K	VITK	84597	Up to 1 times per year without diagnosis limitations applied at this time	LMN	L34914	Assays of Vitamins and Metabolic Function
BETA HCG, SERUM	BHCGH	84702	It is not reasonable and necessary to perform hCG testing more than once per month for diagnostic purposes. It may be performed as needed for monitoring of patient progress and treatment. Qualitative hCG assays are not appropriate for medically managing patients with known or suspected germ cell neoplasms.	BOTH	190.27	Human Chorionic Gonadotropin
FIBRONOGEN ANTIGEN		85385	Up to 3 times per year with supporting dx	BOTH	L34914	Assays of Vitamins and Metabolic Function
ALLERGEN IGE	Various Codes	86003	CPT code 86003 will be covered for only thirty (30) units in a year.	BOTH	L36241	Allergy Testing
C-REACTIVE PROTEIN HIGH SENSITIVITY TESTING	HSCRP	86141	It is considered reasonable and necessary to perform no more than 3 hsCRP services per patient lifetime.	BOTH	L34856	C-Reactive Protein High Sensitivity Testing (hsCRP)
HUMAN PAPILLOMAVIRUS	HPV	87624	HPV testing once every five years as an additional preventive service benefit under the Medicare program for asymptomatic beneficiaries aged 30 to 65 years in conjunction with the Pap smear test. (Use ICD-10 code Z12.4 and Z11.51).	BOTH		Screening Pap Tests & Pelvic Exams
GLUCOSE TESTS FOR DIABETIC SCREENING		82947 82950 82951	1 screening every 6 months for patients diagnosed with pre-diabetes 1 screening every 12 months if previously tested but not diagnosed with pre-diabetes or if never tested (Use ICD-10 code Z13.1).	BOTH		Diabetes Screening
PSA, TOTAL, PROSTATE SPECIFIC ANTIGEN - screening	PSAST	G0103	Annually. All male Medicare beneficiaries aged 50 and older (coverage begins the day after 50th birthday, Z12.5)	BOTH	NCD 210.1	National Coverage Determination (NCD) for Prostate Cancer Screening Tests
PAP SCREEN	N/A	G0123 G0145 P3000	Annually if at high risk for developing cerv or vag CA, or childbearing age with abnormal PAP within past 3 yrs, every 24 months for all other women. (Use ICD-10 codes: High risk – Z77.22, Z77.9, Z91.89, Z72.89, Z72.51, Z72.52, AND Z72.53 / Low risk – Z01.411, Z01.419, Z12.4, Z12.72, Z12.79, and Z12.89).	BOTH	NCD 210.2	National Coverage Determination (NCD) for Screening Pap Smears and Pelvic Examinations for Early Detection of Cervical or Vaginal Cancer
HPV SCREEN	N/A	G0476	Once every 5 years	BOTH	NCD 210.2.1	Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests