This First Coast Billing and Coding Article for Local Coverage Determination (LCD) L37798 4Kscore Test Algorithm provides billing and coding guidance for diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in the LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
Refer to the LCD for reasonable and necessary requirements and limitations.
The redetermination process may be utilized for consideration of services performed outside of the reasonable and necessary requirements in the LCD.
Coding Guidelines
Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.
Documentation Requirements
- All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
- Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
- The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
- Documentation of shared decision making (SDM)), concerning the 4Kscore testing, between the ordering provider and patient must be present in the medical record and a copy of same shall be provided to the performing laboratory prior to the test being performed.
- A simple notation that SDM occurred is insufficient for documentation. The actual process must be documented in the patient’s record.
- The document(s) shall be dated and include the ordering provider and patient’s names and signatures legibly noted to attest that the SDM occurred.
Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Compliance with the provisions in LCD L37798, 4Kscore Test Algorithm may be monitored and addressed through post payment data analysis and subsequent medical review audits.
