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National Coverage Determination (NCD)

Obsolete or Unreliable Diagnostic Tests

300.1

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Tracking Information

Publication Number
100-3
Manual Section Number
300.1
Manual Section Title
Obsolete or Unreliable Diagnostic Tests
Version Number
2
Effective Date of this Version
06/19/2006
Ending Effective Date of this Version
Implementation Date
06/19/2006
Implementation QR Modifier Date

Description Information

Benefit Category
Diagnostic Tests (other)


Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description
Indications and Limitations of Coverage

A. Diagnostic Tests

Do not routinely pay for the following diagnostic tests because they are obsolete and have been replaced by more advanced procedures. The listed tests may be paid for only if the medical need for the procedure is satisfactorily justified by the physician who performs it. When the services are subject to the Quality Improvement Organization (QIO) Review, the QIO is responsible for determining that satisfactory medical justification exists.

When the services are not subject to QIO review, the A/B Medicare Administrative Contractor is responsible for determining that satisfactory medical justification exists. This includes:

  • Amylase, blood isoenzymes, electrophoretic,
  • Chromium, blood,
  • Guanase, blood,
  • Zinc sulphate turbidity, blood,
  • Skin test, cat scratch fever,
  • Skin test, lymphopathia venereum,
  • Circulation time, one test,
  • Cephalin flocculation,
  • Congo red, blood,
  • Hormones, adrenocorticotropin quantitative animal tests,
  • Hormones, adrenocorticotropin quantitative bioassay,
  • Thymol turbidity, blood,
  • Skin test, actinomycosis,
  • Skin test, brucellosis,
  • Skin test, psittacosis,
  • Skin test, trichinosis,
  • Calcium, feces, 24-hour quantitative,
  • Starch, feces, screening,
  • Chymotrypsin, duodenal contents,
  • Gastric analysis, pepsin,
  • Gastric analysis, tubeless,
  • Calcium saturation clotting time,
  • Capillary fragility test (Rumpel-Leede),
  • Colloidal gold,
  • Bendien's test for cancer and tuberculosis,
  • Bolen's test for cancer,
  • Rehfuss test for gastric acidity, and
  • Serum seromucoid assay for cancer and other diseases.

B. Cardiovascular Tests

Do not pay for the following phonocardiography and vectorcardiography diagnostic tests because they have been determined to be outmoded and of little clinical value. They include:

  • Phonocardiogram with or without ECG lead; with supervision during recording with interpretation and report (when equipment is supplied by the physician),
  • Phonocardiogram; tracing only, without interpretation and report (e.g., when equipment is supplied by the hospital, clinic),
  • Phonocardiogram; interpretation and report,
  • Phonocardiogram with ECG lead, with indirect carotid artery and/or jugular vein tracing, and/or apex cardiogram; with interpretation and report,
  • Phonocardiogram; without interpretation and report,
  • Phonocardiogram; interpretation and report only,
  • Intracardiac,
  • Vectorcardiogram (VCG), with or without ECG; with interpretation and report,
  • Vectorcardiogram; tracing only, without interpretation and report, and,
  • Vectorcardiogram; interpretation and report only.
Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
48
Coverage Transmittal Link
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R48NCD.pdf
Revision History

03/2006 - Delete coding information. Effective/Implementation date: 06/19/2006. (TN 48) (CR4278)

04/01/1997 - Excluded coverage of 10 phonocardiography and vectorcardiography diagnostic tests.  Effective 1/1/1997. (TN 96)
Other

National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Obsolete or Unreliable Diagnostic Tests 2 06/19/2006 - N/A You are here
Obsolete or Unreliable Diagnostic Tests 1 01/01/1997 - 06/19/2006 View
CPT Copyright Statement
CPT only copyright 2002-2011 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.
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