Practice Management Alert

A little-known automated test list for lab reimbursement is to blame


If you've noticed that Medicare doesn't reimburse the full amount you expect on claims for a comprehensive metabolic panel and a lipid panel, you're not alone. And you can save time by understanding why an appeal won't make any difference.

Providers often order a comprehensive metabolic panel (CMP) (80053) and a lipid panel (80061) together. Yet if you report these two codes on the same claim, Medicare will pay you about $7.28 less than you seemingly deserve.

Explanation: Medicare appears to underpay on these claims because of a little-known automated test list that defines Medicare's lab code reimbursement, says William Dettwyler, MT-AMT, president of Codus Medicus, a laboratory coding consulting firm in Salem, Ore.
 
The basics: There are 22 lab tests on Medicare's automated test list, including all 14 of the component tests in the CMP (such as albumin [82040], calcium [82310], etc.) and the cholesterol (82465) and triglyceride (84478) tests in the lipid panel. The third component test of the lipid panel - the HDL cholesterol test (83718) - is not on the automated test list, Dettwyler says.

Do the math: Medicare pays the same amount for 13 to 16 automated tests, meaning you'll receive the same reimbursement for 13, 14, 15 or 16 tests, Dettwyler says. When Medicare receives a claim for the CMP and lipid panel, it splits up those two codes into all of their component tests (14 from the CMP and three from the lipid panel) and pays you according to the total number of automated tests.

So Medicare pays you for 16 automated tests under a code called ATP 16 (ATP stands for "automated test panel," and 16 is for the number of tests) and then pays you an additional amount for the HDL cholesterol test that isn't included on the automated test list. The resulting payment is less than you would receive for each test separately.

Automated Test List Is No Secret

ATP 16 is not on the Medicare fee schedule as a billable code - it is only present on the Medicare payment system as a payable code, Dettwyler says. But Medicare carriers do share this information with providers, who often overlook it. If you sort through your Medicare documents or ask personnel in your in-office lab, you should find a copy of the automated test list and an explanation, he says. This may also help you solve other lab reimbursement problems.

Save your appeals: In the meantime, you can prevent further hassle by pulling the brakes on appeal efforts for CMP and lipid panel claims.