Pathology/Lab Coding Alert

Question: A physician ordered a hepatitis panel with diagnosis code 070.51, but Medicare denied payment. What could be the problem?

Kansas Subscriber

Answer: Although 070.51 (Acute hepatitis C without mention of hepatic coma) is on the “ICD-9 codes covered by Medicare” list in the laboratory National Coverage Determination (NCD) for hepatitis panel, many factors could lead to a denial.

Based on symptoms such as fatigue, weight loss, and jaundice, the physician may order a hepatitis panel (80074, Acute hepatitis panel), which includes individual tests for hepatitis B surface antigen (87340), hepatitis C antibody (86803), hepatitis B core antibody (HBcAb), IgM antibody (86705), hepatitis A antibody (HAAb), and IgM antibody (86709).

Know panel medical necessity: CMS gives three indications of when your physician may provide a hepatitis panel:

• To detect viral hepatitis infection when there are abnormal liver function test results, with or without signs or symptoms of hepatitis
• Prior to and subsequent to liver transplantation
• As a repeat panel for patients with a negative panel result when the time of exposure or stage of the disease is unknown.

Possible denial: According to CMS, after the physician establishes a diagnosis of hepatitis, you may report only individual tests, as necessary, rather than the entire panel (80074). In other words, a physician should not repetitively order this test panel for a single patient when monitoring progress or changes after he has identified the initial specific cause of hepatitis. Because you state that the patient has a firm diagnosis (070.51), the denial may stem from lack of medical necessity based on a prior recent hepatitis panel.

Resource: You can read more about the lab NCD at www.cms.hhs.gov/CoverageGenInfo/downloads/manual201001.pdf#22