Pathology/Lab Coding Alert

Labs that perform heart-disease screening tests are probably expecting their carrier to pay under Medicare's cardiovascular screening benefit. But your lab could be left footing the bill unless the ordering physician correctly assigns a screening diagnosis code and follows frequency guidelines.

Follow these four steps to make sure your lab gets paid for cardiovascular disease screening -- every time.

Physicians perform cardiovascular screenings to detect certain heart conditions, such as coronary artery disease or peripheral arterial disease, says Mary Franklin, coding/billing specialist at Virginia Medical Alliance in Springfield.

Distinguish screening: Don't confuse screening and diagnostic services, even though they may involve the same lab tests. A physician orders a screening test for "early detection of cardiovascular disease in individuals without apparent signs or symptoms," according to CMS.

There are four types of screenings available to physicians, says Sean M. Weiss, CPC, CPC-P, CMPE, CCA-P, CCP-P, senior partner at The CMC Group LLC in Atlanta. The tests the lab performs will depend on the patient:

- Total cholesterol. This test measures the patient's total cholesterol. Code these screenings with 82465 (Cholesterol, serum or whole blood, total).

- Cholesterol test for high-density lipoproteins. This test checks the patient's level of "good" cholesterol. Code these screenings with 83718 (Lipoprotein, direct measurement; high-density cholesterol [HDL cholesterol]).

- Triglycerides. This test checks the patient's triglyceride levels. Code these screenings with 84478 (Triglycerides).

- Lipid panel. Although the physician might order one of the above screens individually, he could also request all three of the tests, in which case the lab should report 80061 (Lipid panel) for the service.

Hidden trap: If the physician orders two tests -- such as total cholesterol and triglycerides -- you can't use the panel code. But your carrier may not pay for both tests because the coverage criteria stipulate 80061, 82465, 83718 or 84478.

No matter what screening tests the physician orders for the patient, Medicare requires you to include one of these diagnosis codes on the claim. You are likely to receive a payer denial without one of these codes:

Because the ordering physician -- not the performing lab -- assigns the diagnosis code, your lab's first defense is to make sure your physician clients know the Medicare rules.

Physicians who order cardiovascular screenings for Medicare patients also need to be aware of frequency guidelines for the tests, Franklin says.

The basics: Medicare will pay for one cardiovascular screening every five years for its patients, Weiss says. Carriers will deny your screening claims if "there is already evidence of a paid claim within the prior 60 months with a diagnosis code of V81.0, V81.1 or V81.2, along with a procedure code of 80061, 82465, 83718 or 84478," he says.

So if a Medicare patient had a total cholesterol screen (82465) today, he would not be able to have any covered cardiovascular screens (82465, 83718, 84478 or 80061) for five years. And you have to make sure it has been at least five years since the last screen, Weiss says.

If the lab performs the screening even one day prior to the expiration of the five-year "between test" period, Medicare will deny the service on the basis of frequency guidelines. Medicare payers "are sticklers for dates," Weiss says.

For more information on determining a beneficiary's eligibility for Medicare preventive services, see http://www.cms.hhs.gov/MLNProducts/downloads/Preventive_Services_Eligibility.pdf.

Experts recommend that you have a signed advance beneficiary notice (ABN) on file for patients who get cardiovascular screenings. That way, if the payer denies the screening claim, you can bill the patient for the services. Otherwise, your lab may get stuck with the tab for many circumstances, such as a patient who doesn't remember a prior lipid screen but who actually exceeds the frequency guidelines.

Educate physicians: Labs often have no control over getting the ABN, unless the patient comes to the lab for the blood draw. As with other parts of the process, you-ll have to educate your physician clients to get an ABN at the time they order the test.