Cardiology Coding Alert

Question: We perform our own lipid screening, and we're having problems with Medicare payment. 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 many restrictions on the coverage, and your billing could be running afoul of Medicare's 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 all three tests, Medicare will pay for the lipid panel (80061). But if the physician orders two of the tests -- such as total cholesterol and triglycerides -- you cannot use the panel code. And your carrier may not pay for both tests because the coverage criteria stipulate payment for one code.

2. Ordering diagnosis: Medicare will pay for lipid screening only 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.

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.