Pathology/Lab Coding Alert

Question: Were having problems with Medicare payment for lipid screening. I thought this was one of the covered preventive services. What could be the problem?

Wisconsin Subscriber

Answer: You are correct that Medicare will cover lipid testing to screen patients for heart disease as a preventive service. But Medicare places plenty of restrictions on the coverage, and your billing could be running afoul of Medicares requirements in one of three areas:

1. Covered tests: Medicare will pay for one approved code from the following list:

" 80061 -- Lipid panel. This panel must include the following & 82465&83718&84478

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

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

" 84478 -- Triglycerides.

Trap: If the physician orders two tests -- such as total cholesterol and triglycerides -- you cant use the panel code.But your carrier may not pay for both tests because the coverage criteria stipulate 80061, 82465, 83718, or 84478.

Although Medicare will pay for the lipid panel, which includes the three other tests, Medicare wont pay for two of the tests if the physician orders them separately.

2. Ordering diagnosis: Medicare will only pay for lipid screening if the claim contains one of the following diagnosis 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.

Because the ordering physician -- not the performing lab -- assigns the diagnosis code, your first defense is to make sure your physician clients know the Medicare rules.

3. Frequency limits: Medicare will pay for one cardiovascular screening every five years. Carriers will deny your screening claims if there is already evidence of  a paid claim within the prior 60 months with a diagnosis code of V81.0, V81.1, or V81.2, along with a procedure code of 80061, 82465, 83718, or 84478.

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