Healthcare Professionals
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 |