(Reproduced by permission from Medicare Focus, August, 1997, pp. 49 - 51.)

Medicare Part A
Local Medical Review Policy

Syphilis Tests; Qualitative (e.g., VDRL, RPR)

Policy Number: 96-12

Description

86592

Syphilis tests; qualitative (e.g., VDRL, RPR, ART)

Type of Bill: 13X, 14X, 22X, 23X, 71X, 74X, 75X

Revenue Codes: 300-319

Indications and Limitations

Syphilis testing is performed to:

• Assist in the diagnosis of primary and secondary syphilis.
• Confirm primary or secondary syphilis in the presence of syphilitic lesions.
• Monitor response to treatment.

A qualitative syphilis test is covered under Medicare Part A when it is considered medically reasonable and necessary for the following:

HCPCS Codes: 86592

Diagnosis Codes for Coverage

ICD-9 diagnosis codes should be used at their highest level of specificity.

Category: Pathology and Laboratory

Reason for Denial

Routine screening

Noncovered Diagnosis Codes

Any diagnoses other than those listed will be denied without additional documentation.

Sources of Information

Diagnostic Tests Handbook, Springhouse Corporation, 1987
Laboratory and Diagnostic Tests, Fifth Edition, Lippincott, 1996
Other Carriers' Policies

Coding Guides

Use CPT code 86592 when billing for a qualitative syphilis test.

Documentation Required

ICD-9-CM diagnosis codes are required on claim.

Medical records must clearly document the medical necessity for the test and the frequency of the test.

If documentation is requested for review, submit the following:

• History and Physical
• MD orders/progress notes
• Diagnosis/reason for test
• Test results
• Itemization of charges

Comments

This policy is being adapted from the Carrier policy. It does not represent the sole opinion of the Intermediary/Medical Director. This policy was developed in consultation with the medical community and the Carrier Advisory Committee.

Approval Dates