Pathology/Lab Coding Alert

Question: Physicians often order lipid testing for patients diagnosed with benign hypertension because they may have an increased risk of heart disease, but we've received Medicare denials for the tests as "not medically necessary." Why is this, and what can we do to get paid for these tests, such as a lipid panel (80061)? Illinois Subscriber Answer: The bad news is that you're right: Labs have received denials for lipid tests ordered with a benign hypertension diagnosis since Medicare instituted the National Coverage Determination (NCD) for lipid testing. The good news is that Medicare recently announced its intention to modify the NCD to correct the situation. Medicare will add the phrase "any disease leading to the formation of atherosclerotic disease" - which includes all forms of hypertension - to its list of coverage indications. The agency will also add 401.1 (Essential hypertension; benign) to the list of covered ICD-9 codes. CMS says that benign essential hypertension is a common precursor to atherosclerotic disease in its National Coverage Analysis #CAG-00188N. You can view the coverage analysis at http://www.cms.gov/ncdr/memo.asp?id=94. The lipid NCD impacts coverage for the following CPT codes: 80061 - Lipid panel 82465 - Cholesterol, serum or whole blood, total 83715 - Lipoprotein, blood; electrophoretic separation and quantitation 83716 - Lipoprotein, blood; high-resolution fractionation and quanti-tation of lipoprotein cholesterols (e.g., electrophoresis, nuclear magnetic resonance, ultracentrifugation) 83718 - Lipoprotein, direct measurement; high-density cholesterol (HDL cholesterol) 83721 - Lipoprotein, direct measurement; LDL cholesterol 84478 - Triglycerides. - Reader Questions and You Be the Coder were prepared with the assistance of Laurie Castillo, MA, CPC, CPC-H, CCS-P, president of Professional Coding and Compliance Consulting in Manassas, Va.