Revenue Cycle Insider

Question: If our clinical laboratory processes an automated lipid panel (80061) that includes total cholesterol, HDL, and triglycerides, but also performs an independent automated direct LDL measurement (83721) on the same patient sample, how should we report these services to avoid unbundling denials?

Revenue Cycle Insider Subscriber

Answer: Billing 80061 (Lipid panel. This panel must include the following: Cholesterol, serum, total (82465)Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718)Triglycerides (84478)) along with 83721 (Lipoprotein, direct measurement; LDL cholesterol) is a heavily audited compliance scenario, which is why it was the subject of a Department of Health and Human Services (HHS) Office of Inspector General (OIG) investigation in 2021.

The findings of the investigation, however, provide the answer to your question. The OIG report states the following:

If the triglyceride level is less than 400 mg/dl, the LDL is a calculated value utilizing the results from the lipid [panel] for the calculation, and CPT^® code 83721 is not separately reportable. However, if the triglyceride level is greater than 400 mg/dl, the LDL may be measured directly and may be separately reportable with CPT^® code 83721 utilizing an NCCI-associated modifier to bypass the edit.

In other words, if the medical record shows the lipid panel (80061) has resulted in a triglyceride level ≥ 400 mg/dl, the level is too high to be measured by a calculation. This provides the medical necessity for the provider to go ahead and order a direct measurement of the patient’s LDL cholesterol using the test described by 83721. Otherwise, if the level is below the 400 mg/dl threshold, you cannot bill the two tests together.

However, if the result does exceed the 400 mg/dl threshold, as 83721 is a column 2 code in a National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edit pair with 80061, and the edit pair has a modifier indicator of “1,” you will need to override the edit by appending modifier 59 (Distinct procedural service) or XU (Unusual non-overlapping service) to the 83721 depending on payer preference.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC