2 Expert Q&A's Help Solve Your Trickiest Lipid Panel Questions

You can't afford to miss this advanced lab coding info on 83721, 80061 and 80053
If you think coding for lab panels is a piece of cake, think again. While reporting the appropriate codes may be easy enough, adding the correct modifiers and determining proper reimbursement can be a major challenge.
 
Check out our experts' answers to the two advanced lab coding questions below to discover coding nuances you may have never known exist.
Question #1: When is it acceptable to use modifier -59 (Distinct procedural service) to unbundle 80061 and 83721?
 
Answer: Physicians often order both a lipid panel (80061) and an LDL cholesterol measurement (83721) because both tests provide important information about the patient's lipid profile, says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. The problem with this approach is that many laboratories calculate the LDL based on the triglyceride result and other results of the lipid panel, rather than performing a separate direct measurement.
 
CMS indicates "direct measurement of LDL cholesterol (83721) or lipid panel (80061) may be reasonable and necessary if the triglyceride level is too high to permit calculation of the LDL cholesterol." If the LDL by calculation is valid, you should not bill separately for the LDL cholesterol measurement - this is why the National Correct Coding Initiative bundles 83721 with 80061.
 
No payment unless: Medicare will only pay on 83721 for the separately measured LDL test if the patient's triglyceride result is above a level that allows for a valid result by calculation. This means that if your lab performs a separate LDL measurement for a patient whose triglyceride isn't too high, you shouldn't bill separately for the test, Dettwyler says.
 
Use modifier -59 when: If the patient's triglyceride result is too high and your lab performs a separate LDL direct measurement, you are entitled to payment for both 80061 and 83721. To ensure payment, append modifier -59 to 83721 so your claim will bypass Medicare's bundling edit, says Norma Aguilar, a coder and biller with Southwest Endocrine Consultants in El Paso, Texas.
 
Medicare does not clearly define the exact triglyceride level above which providers can bill the LDL measurement separately, Dettwyler says. Because Medicare's instructions are unclear, many labs misunderstand this bundling requirement and report all their LDL measurements with modifier -59, he adds.
 
Beware: You will get paid if you report 83721 with modifier -59, but that doesn't mean you deserve the payment. In the event of an audit, your practice could be forced to pay back the cost of all the unjustified LDL measurements you charged to Medicare, Dettwyler says. To protect yourself, make sure your lab determines a set triglyceride level [...]

- Published on 2004-08-26