Pathology/Lab Coding Alert

Abide by 5-year rule or risk denials 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. 1. Know the Covered Screening Tests 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. 2. Educate Physician Clients About Diagnosis Codes 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: - V81.0 -- Special screening for ischemic heart disease - V81.1 -- Special screening for hypertension - V81.2 -- Special screening for other and unspecified cardiovascular conditions. 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. 3. Check Frequency Limits 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 [...]