Local Coverage Determination: KY and OH

November 17, 2011

The recent change of Medicare Part B contractor from Palmetto to Cigna Government Services that took place in July 2011 also brought about changes to the LCD for IHC’s and Flows for Ohio and Kentucky.

An LCD, Local Coverage Determination, is the guideline that is required by CMS for fiscal intermediaries, MAC contractors, and carriers to issue to direct providers how to submit claims for certain services. LCDs also designate diagnosis codes needed to justify medical necessity for services, establish billing guidelines, and include limits on frequency and patient eligibility.

Below are the changes for Immunohistochemistry and Flow Cytometry for CGS that pathologists need to be aware of moving forward. Your billing service should also be aware of the new policies.

LCD L31873 for code 88342 Immunohistochemistry, each antibody

This LCD includes a list of diagnosis codes that CGS feels supports the medical necessity for reimbursement for this service. The list is rather extensive and pertains to many conditions across the organ systems but excludes many common signs & symptoms often associated with pathology billing such as nausea, vomiting, diarrhea, and abdominal pain.

The LCD also imposes limits on the number of payable units per specimen. CGS states that it would be unusual for more than ten (10) units to be medically necessary for one sample of tissue. Units reported above this threshold should be supported in the pathology report.

LCD L31870 for codes 88182 – 88189 Flow Cytometry

The LCD for flow Cytometry also includes a list of diagnosis codes felt to support medical necessity for reimbursement. The list mostly includes neoplasms, conditions of the endocrine, nutritional and metabolic systems, and diseases of the blood and blood-forming organs.

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