Pathology/Lab Coding Alert

Question: I noticed in an earlier reader question that you said we can’t separately bill for a low density lipoprotein (LDL) cholesterol with a lipid panel. But we have standing orders in the lab that if the triglyceride level is ≥ 400 mg/dl, we reflex to a direct LDL test. Can’t we bill separately for that test?

New Mexico Subscriber

Answer: The question you’re referring to is “Zero In on Lipid Order for Proper Coding” in Pathology/Lab Coding Alert Vol. 17, No. 1. That question mentioned that you should not bill for a calculated LDL value that is based on the results of the measured total and high density cholesterol (HDL) fraction. The measured values were acquired as part of a lipid panel (80061, Lipid panel), which includes total cholesterol (82465), HDL cholesterol (83718) and triglycerides (84478).

The situation you’re describing is different, because you’re actually performing a separate test to measure the LDL fraction (83721, Lipoprotein, direct measurement; LDL cholesterol). In that case, it is appropriate to report 83721 in addition to the lipid panel (80061).

Caution: Correct Coding initiative bundles 83721 as a column 2 code with 80061. You may be able to override the edit with an appropriate modifier such as 59 (Distinct procedural service) on 83721, but you should check with payers for their guidelines. For instance, Anthem Central Region allows you to override the edit pair for reflex testing for fasting triglyceride ≥ 400 mg/dl and certain other situations, such as fasting precluded.

Beware screening test: Properly applied, a reflex test means that the physician orders a test with a statement that the lab will “reflex” to another test a certain clinical level (triglycerides ≥ 400 mg/dl, in this case). In that way, the physician is ordering both the initial test and the reflex test, when needed. But the Medicare cardiovascular screening benefit covers 80061 or its component tests, but not an LDL test (83721).

Work around: If you allow physicians an opportunity to order a screening lipid panel without a reflex test (Z13.6, Encounter for screening for cardiovascular disorders), upon viewing the results of a triglyceride level  ≥ 400 mg/dl, the physician can order the LDL test based on the findings (E78.1 Pure hyperglyceridemia).