Pathology/Lab Coding Alert

Question: Why do some codes, such as 80050 and 80051, not have an associated RVU value on the Medicare fee schedule -- does that mean the test isn't covered?

Wisconsin Subscriber

Answer: No, lack of relative value units (RVUs) on the Medicare Physician Fee Schedule (PFS) doesn't necessarily mean the test isn't covered.

RVUs are based on the pricing established by CMS. If a CPT® procedure code does not have an RVU, it may mean that Medicare does not cover the service, or it may mean that the agency uses another avenue to pay for the test. You can find out where Medicare stands on the payment status of any particular code by checking the PFS.

Key: When perusing the PFS, check the "Status Code" column (Column D). If a code with zero RVUs assigned to it has an "N" in column D, you won't collect Part B payment from any Medicare contractors for that service, as it's a considered a "noncovered service." For instance, the PFS lists 80500 (General health panel) with status code N, because 80500 is a screening test, which Medicare won't cover.

For many lab tests, such as 80051 (Electrolyte panel), you'll see status indicator "X," which means "statutory exclusion." In other words, "these codes represent an item or service that is not in the statutory definition of 'physician services' for fee schedule payment purposes," according to CMS.

Look to CLFS: Most clinical lab tests don't require direct physician service, so they're statutorily excluded for payment on the PFS. That doesn't mean Medicare won't cover the tests or pay for them -- the agency just uses a different fee schedule for lab tests. That's the Clinical Lab Fee Schedule (CLFS), and you'll find a payment amount for 80051 on that list.

Watch for carrier: If a code has a "C" in Column D, it will be listed with zero RVUs, but your MAC may still reimburse you for it. That's because "C" refers to a "carrier-price code." Individual Medicare contractors will establish the RVUs and payment amounts for these services, typically on a case-by-case basis after reviewing the documentation.