Question:

How often does Medicare cover screening tests?

Answer:

With few exceptions, you will typically find that the preventive screening tests covered by Medicare are covered once per year. (Exceptions include two screening tests per year for beneficiaries diagnosed with prediabetes and cardiovascular screening tests, which are covered every five years.) Diagnostic procedures included in either local or national coverage determinations have varying frequency limitations depending on the test and the diagnosis. Tests (such as Hgb A1C) are paid once per quarter. Because the same procedure codes may be covered as either a preventive screening benefit or a diagnostic service benefit, it is absolutely essential that the CPT® as well as diagnosis information accurately represent the test performed and the reason for the test.

To monitor overutilization, have your information management department print out your volume statistics in descending order by CPT code. Count down your top 30 tests and draw a line. Repeat either monthly or quarterly, and document any tests that vary by 10 percent or more. If you can tailor the information to exclude inpatients and payers other than the federally funded programs, you’ll have an even better monitor.


CPT® is a registered trademark of the American Medical Association.

This question was answered in the 2018 edition of Coding Essentials for Laboratories. For more hot topics relating to laboratory services, please view our store, or call us at 1.800.252.1578 ext. 2.

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CPT® copyright 2021 American Medical Association (AMA). All rights reserved.

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.

CPT is a registered trademark of the American Medical Association.