CMS Pub. 100-08, ch. 3, § 3.2.3.7

This section applies to MACs, CERT, RACs, UPICs, and SMRC as

indicated.

ICD-10-CM is used for diagnoses on inpatient discharges and for other services provided

upon implementation of ICD-10.

When the MACs, CERT, RACs, SMRC, and UPICs send an ADR for a lab service, the

following documentation shall be requested from the billing lab:

• The order for the service billed (including sufficient information to

allow the reviewer to identify and contact the ordering provider);

• Verification of accurate processing of the order and submission of

the claim; and

• Diagnostic or other medical information supplied to the lab by the

ordering provider, including any diagnosis codes or narratives.

The contractor shall deny the claim if a benefit category, statutory exclusion, or coding

issue is in question, or send an ADR to the ordering provider to determine medical

necessity. The contractor shall review information from the lab and find it insufficient

before the ordering provider is contacted. The contractor shall send an ADR to the

ordering provider that shall include sufficient information to identify the claim in

question.

If the documentation received does not demonstrate that the service was reasonable and

necessary, the contractor shall deny the claim. These denials are considered medical

record reviews. Contractor denial notices shall remind providers that beneficiaries cannot

be held liable for these denials unless they received proper liability notification before

services were rendered, as detailed in CMS Pub. IOM 100-04, chapter 30.