Pathology/Lab Coding Alert

Acknowledge frequency and diagnosis restrictions.

Medicare -- and other payers -- cover lipid screening, which could create a high test volume in your lab. That's why you need to know the ins and outs of coverage rules to make sure you're capturing all the pay you deserve. Know the Tests

Physicians may order any or all of the following tests to screen for cardiovascular disease, according to CMS:

• 82465 -- Cholesterol, serum or whole blood, total
• 83718 -- Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
• 84478 -- Triglycerides test.

"Note that these three tests comprise the lipid panel, so if the lab performs all three tests, you should report 80061 (Lipid panel) instead of the individual test codes," says William Dettwyler, MT AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore. "Medicare will pay for the individual tests when ordered separately, however."

From a clinical standpoint, ordering the full panel makes sense, says Ashleigh A. Raubenolt, CPC, CPC-H, CPC-P, CPMA, CEMC, CHCA, director of Chart Watch Auditing and Review, and Credentialing and Physician Contracting, at S.A. Medical of Virginia Inc. in Fredericksburg. For instance, if a cholesterol test came back abnormal, the physician would need to know whether the HDL and, potentially, the low density lipoprotein (LDL) measurements were high or low to treat the patient, Raubenolt continues.

Don't double dip calculated LDL: Although physicians may need to know LDL, and CPT provides a code for the test (83721, Lipoprotein, direct measurement; LDL cholesterol) you'llnotice that it's not a covered test for screening. "That's because the lab typically calculates LDL from the other lipid fractions measured in a lipid panel, so you shouldn't separately charge for a calculated value," Dettwyler says. "Although 83721 is not part of the screening coverage, Medicare may pay for direct-measure LDL as a diagnostic test under certain circumstances."

Use QW for waived labs: If you're a waived-status lab under the Clinical Laboratory Improvement Amendments (CLIA), don't forget to report the lipid tests 82465, 83718, 84478, or 80061 with modifier QW (CLIA waived test).

'No Symptoms' Means Screening

Medicare and other payers cover lipid screening blood tests for asymptomatic patients. That means that the beneficiary must have "no apparent signs or symptoms of cardiovascular disease," according to the Guide to Medicare Preventive Services (www.cms.gov/MLNProducts/downloads/mps_guide_web-061305.pdf). When a patient has symptoms, the test becomes diagnostic rather than a screening.

Have an order: Make sure that the medical record documentation reflects that a physician or qualified nonphysician practitioner (NPP) ordered the test. Because lipid-test accuracy depends on patient fasting, you also need to document that the patient hasn't eaten for 12 hours prior to testing.

Look for These Diagnoses

Since the screening test is for asymptomatic patients, you won't have an ICD-9 condition or symptom code to show medical necessity for the test. Instead, the ordering physician should provide the lab with one of the following V codes when ordering lipid screening tests:

• V81.0 -- Special screening for ischemic heart disease
• V81.1 -- ... hypertension
• V81.2 -- ...other and unspecified cardiovascular conditions.

You may select more than one V code, says Raubenolt, but always indicate the primary reason the patient is receiving this service.

For instance: The patient has a family history of ischemic heart disease but is currently asymptomatic. No other family history is noted. In this case, you would report only V81.0, the special screening for ischemic heart disease. If the patient has multiple family history conditions, such as heart disease and hypertension, then you may select both relevant ICD-9 codes (V81.0 and V81.1).

If you find no reason for the screening indicated in the chart, ask the physician why she ordered the screening, recommends Raubenolt. "Even though a patient may be asymptomatic, there has to be a reason to prompt the physician to order the screening," she says. And knowing that reason "will direct coders to the appropriate code selection," she adds.

Alternate diagnoses: Codes V81.0-V81.2 are the diagnoses that come up as "payable" without questions. But many payers also may reimburse for conditions such as 278.01 (Morbid obesity) and 250.xx (Diabetes mellitus) if the patient is more than 50 years old, says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CCC, CEMC, CMC, healthcare coding consultant and CEO/President of Terry Fletcher Consulting Inc. in Laguna Beach, Calif. Always check with the individual payer for guidance on covered diagnoses.

Watch Frequency Limits

Medicare only covers screening lipid testing once every five years. To be exact, you must make sure that at least 59 months have passed since the last covered cardiovascular screening blood test.

You can expect denials if "the beneficiary received a covered lipid panel [or] the same individual cardiovascular screening blood test during the past five years," according to the Guide to Medicare Preventive Services. That means the five-year frequency limit for each test applies regardless of whether the physician ordered the tests individually or in a panel.

For example: If one doctor ordered a screening total cholesterol (82465), then another ordered a screening lipid panel (80061) within the five-year time period, the second physician won't get paid for total cholesterol.

Revenue tip: Make sure referring physicians are familiar with the coverage criteria. Use an advance beneficiary notice (ABN) to make patients aware of what they could be paying out of pocket should their insurer not allow for the services (if, for instance, the patient has forgotten that he had a screening three years ago). "Education is the key to making sure you're bringing in every legitimate dollar," Fletcher says.