Pathology/Lab Coding Alert

Question: We often receive Medicare denials for screening cholesterol or lipid tests even when the ordering physician uses an appropriate screening code such as V81.0. What could be the reason for the denials, and how can we get paid for the tests we perform?

Tennessee Subscriber

Answer: As you indicated, Medicare covers certain screening tests for cardiovascular disease. The covered tests include the following:

- 80061 -- Lipid panel

- 82465 -- Cholesterol, serum or whole blood, total

- 83718 -- Lipoprotein, direct measurement; high-density cholesterol (HDL cholesterol)

- 84478 -- Triglycerides.

You also correctly indicated that the physician must order the screening exam with an appropriate diagnosis code for Medicare to cover the test. You are likely to receive denials 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.

Since you have apparently eliminated these reasons for denial, one possibility that remains is that the physician orders a test more frequently than Medicare allows.

Medicare will pay for one cardiovascular screening every five years. Carriers will deny your screening claims if the carrier has paid a claim within the past 60 months for any of the listed screening diagnosis codes linked to any of the covered tests.

Example: If a Medicare patient had a total cholesterol screen (82465) today, he would not be able to have any covered cardiovascular screens (80061, 82465, 83718, 84478) for five years.

Protect yourself: The only opportunity for you to capture payment for these tests is to have a signed advance beneficiary notice (ABN) on file. That way you can bill the patient if Medicare denies the charge.