Pathology/Lab Coding Alert

Question: Our lab wants to add LDL to the lipid panel so when physicians order the panel, they will automatically get the LDL as well as the tests bundled with 80061. Can we bill for the panel and the added test separately?

Georgia Subscriber Answer: The physician who orders the lab work must show medical necessity for each test ordered, so automatically bundling tests could leave your lab without the requirements for payment.
 
The lipid panel 80061 (Lipid panel) includes the following tests:

  82465 - Cholesterol, serum, total
  83718 - Lipoprotein, direct measurement, high-density cholesterol (HDL cholesterol)
  84478 - Triglycerides. Both the 80061 panel and the LDL test (83721, Lipoprotein, direct measurement; LDL cholesterol) are part of Medicare's National Coverage Determination for lipid testing, meaning they share the same list of covered ICD-9 diagnoses. However, you cannot always report these two services together.
 
Some carriers specifically restrict the use of 80061 and 83721 together. For example, Blue Cross Blue Shield of Arkansas states that you should only perform a measured LDL (83721) with documented triglycerides greater than 400. Otherwise, labs should use the calculation method for LDL (LDL cholesterol = total cholesterol - HDL cholesterol - [triglycerides/5]). Medicare and other payers will not reimburse the lab for a calculation.
 
Because you can calculate LDL from the results of the three tests in the lipid panel, NCCI version 9.1 added an edit pair for 80061 and 83721 in April 2003. If your lab actually performs the 80061 panel and also performs a medically necessary separate LDL (87321) due to elevated triglycerides, for example, you should append modifier -59 (Distinct procedural service) to 87321 to  override the edit pair.