Pathology/Lab Coding Alert

Question: When our lab bills Medicare for a comprehensive metabolic panel and a lipid panel for the same patient on the same day, we don't receive full payment for the tests. None of the tests from these two panels overlap, so why does Medicare reduce the payment, and how can we appeal the underpayment?

Missouri Subscriber

Answer: Medicare has a little-known automated test list that defines the program's lab code reimbursement for multiple automated tests. The list involves 22 lab tests, including all 14 component tests of the comprehensive metabolic panel (80053, Comprehensive metabolic panel) and the cholesterol (82465, Cholesterol, serum or whole blood, total) and triglyceride (84478, Triglycerides) tests in the lipid panel (80061, Lipid panel).

The HDL cholesterol test (83718, Lipoprotein, direct measurement; high-density cholesterol [HDL cholesterol]) on the lipid panel is not on the automated test list.

Medicare's fee schedule pays the same amount for 13 to 16 automated lab tests, meaning you'll receive the same reimbursement for 13, 14, 15 or 16 tests. Medicare adds together the number of automated tests on a claim - in this case, 16 (14 from the comprehensive metabolic panel, plus two from the lipid panel) - and pays you according to the total number.

The automated test list requires Medicare carriers to bundle certain automated tests to prevent excessive payments. When Medicare pays the comprehensive metabolic panel with the lipid panel, you receive about $7.20 less reimbursement than you would for the two panels billed separately (amount varies by payment region).

This little-understood payment catch causes frequent confusion. If you understand the reason behind the lower-than-expected payment on your claims for comprehensive metabolic panels and lipid panels, you can save yourself the time of trying in vain to appeal for underpayment.