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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyProvidence PTT Coverage Update | OpenPayer
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    CurrentProvidence Health PlanPolicy 326

    Partial Thromboplastin Time (PTT)

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    This Medicare medical policy governs coverage and billing of the Partial Thromboplastin Time (PTT) laboratory test for Medicare beneficiaries. Coverage follows Medicare NCD 190.16 and requires applicable Medicare medical-necessity criteria and diagnosis coding.

    Policy Summary
    PayerProvidence Health Plan
    PolicyPartial Thromboplastin Time (PTT)
    Policy CodePolicy 326
    Change TypeICD-10 diagnosis configuration update
    Effective DateOct 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateNov 1, 2026
    Key ActionSubmit the ICD-10-CM diagnosis code applicable to the service date from the current CMS Lab NCDs covered-code list for NCD 190.16.
    SourceLink
    POLICY UPDATE CHANGES

    The ICD-10 diagnosis configuration was updated for the October 2026 CMS update under CR 14536.

    CPT 85730Covered PTT procedure code
    NCD 190.16Applicable coverage determination
    No prior authPrior authorization requirement
    Medicare only

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Product and benefit

    Medicare Coverage Criteria

    Medicare NCD 190.16 coverage

    Covered under Medicare guidelines when all applicable NCD requirements are met.

    Medicare NCD 190.16 requirements

    • Bill the Partial Thromboplastin Time (PTT) with an ICD-10-CM diagnosis code included as medically necessary in the current CMS Lab NCDs ICD-10 covered-code list for NCD 190.16.Covered-code list version applicable to the date of service
    • Meet all applicable medical-necessity and utilization criteria in NCD 190.16.

    Services or items that are direct exclusions of Medicare or the member benefit plan are not covered. This includes services that are cosmetic, not medical in nature, or not medically reasonable and necessary under Title XVIII of the Social Security Act, §1862(a)(1)(A).

    An unlisted code submitted for a non-covered service addressed by this policy will be denied as not covered.

    A Partial Thromboplastin Time (PTT) claim must include an ICD-10-CM diagnosis code recognized as medically necessary on the current NCD 190.16 covered-code list applicable to the date of service. The applicable NCD 190.16 medical-necessity and utilization criteria must also be met; a listed diagnosis alone does not guarantee coverage.

    Billing and Procedure Codes

    Covered CPT CodesCPTCovered
    85730Thromboplastin time, partial (PTT); plasma or whole blood.
    HCPCS CodesHCPCS
    No codes listed

    Provider and Billing Guidance

    Prior Authorization

    No prior authorization required

    Prior authorization is not required for these services. Utilization may nevertheless be subject to audit, and all criteria in NCD 190.16 must be met.

    Documentation Required

    Document the current medically necessary diagnosis

    Submit the ICD-10-CM diagnosis code applicable to the service date from the current CMS Lab NCDs ICD-10 covered-code list for NCD 190.16. Inclusion of a listed diagnosis does not guarantee payment; documentation and all NCD criteria must support medical necessity.

    Documentation Required

    Support NCD medical necessity

    Follow the applicable NCD for additional test coverage, utilization limitations, and testing performed to satisfy facility-specific policies or protocols. All applicable NCD 190.16 medical-necessity and utilization criteria must be satisfied.

    Covered PTT Indication

    Partial Thromboplastin Time (PTT) covered indications

    The PTT is covered under Medicare guidelines and NCD 190.16 only when the following requirements are met.

    Covered indication requirements

    • The service is Partial Thromboplastin Time (PTT), billed as CPT 85730.
    • The claim includes an ICD-10-CM diagnosis code that Medicare identifies as medically necessary on the current CMS Lab NCDs ICD-10 covered-code list for NCD 190.16.Current covered-code list applicable to the date of service
    • All applicable NCD 190.16 medical-necessity and utilization criteria are satisfied.
    Policy Summary
    PayerProvidence Health Plan
    PolicyPartial Thromboplastin Time (PTT)
    Policy CodePolicy 326
    Change TypeICD-10 diagnosis configuration update
    Effective DateOct 1, 2026
    Last ReviewAug 1, 2026
    Next Review DateNov 1, 2026
    Key ActionSubmit the ICD-10-CM diagnosis code applicable to the service date from the current CMS Lab NCDs covered-code list for NCD 190.16.
    SourceLink
    On This Page
    Medicare Coverage CriteriaBilling and Procedure CodesProvider and Billing GuidanceCovered PTT Indication
    Denial Risk

    Diagnosis or NCD criteria not met

    Claims may be denied when the PTT is billed without an ICD-10 diagnosis code included on the current Medicare NCD 190.16 medically necessary covered-code list, when NCD 190.16 criteria are not met, or when utilization does not satisfy applicable Medicare requirements.

    Denial Risk

    Excluded or non-covered services

    Services excluded by Medicare or the member Evidence of Coverage may be denied, including services that are cosmetic, not medical in nature, or not medically reasonable and necessary. An unlisted code submitted for a non-covered service addressed in this policy will be denied as not covered.

    Billing Rule

    Unlisted-code review risk

    All unlisted codes are reviewed for medical necessity, correct coding, and pricing at the claim level. For an unlisted code submitted for a potentially covered service addressed in this policy, prior authorization is recommended to avoid post-service denial.