Pathology/Lab Coding Alert

Question: I've looked on the Clinical Laboratory Fee Schedule for pricing for Calcitonin stimulation panel, which our lab performs, but the payment values are $0. I noticed that all the codes in this range (80400-80440) show no payment -- doesn't Medicare cover these tests?

Maryland Subscriber

Answer: Yes, Medicare may cover some of these tests when the provider demonstrates medical necessity. The absence of a payment rate on the Clinical Laboratory Fee Schedule (CLFS) doesn't indicate lack of coverage.

The tests in the range you mention -- 80400-80440 are evocative/suppression tests. That means the lab takes a baseline test of some blood constituent, then the patient receives a dose of some compound to either evoke or suppress a response, which the lab measures with subsequent blood constituent testing.

You'll notice that each lab code in the 80400-80440 range lists the individual tests that the lab must perform.

For instance: You should report the test you mention as 80410 (Calcitonin stimulation panel [e.g., calcium, pentagastrin], this panel must include the following: Calcitonin [82308x3]).

That means the lab performs three calcitonin tests (82308, Calcitonin) to complete this panel.

Price this: Medicare derives the payment amount for 80410 by summing the national limitation amount (NLA) or the fee schedule amount (whichever is lower) for the individual test codes included in the panel. So rather than looking at the evocative/suppression code on the CLFS to find pricing information, you need to look at the reimbursement amount of the component codes.