Reader Questions:
Diagnosis Is Key for Lipid Tests
Published on Fri Apr 01, 2005
Question: Our lab performs regular lipid testing for patients with disorders such as hyperlipidemia. We often receive denials for these regular cholesterol checks, and would like to know what coding restrictions will help us improve collections for these tests.
North Carolina Subscriber
Answer: Several factors could lead to denials for regular diagnostic lipid testing, such as improper diagnosis coding, or exceeding frequency limits. Medicare's National Coverage Determination for lipid testing addresses these issues when you perform any of the following lab tests:
80061 - Lipid panel
82465 - Cholesterol, serum or whole blood, total
83715 - Lipoprotein, blood; electrophoretic separation and quantitation
83716 - ... high-resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (e.g., electrophoresis, nuclear magnetic resonance, ultracentrifugation)
83718 - Lipoprotein, direct measurement; high-density cholesterol (HDL cholesterol)
83721 - ... direct measurement, LDL cholesterol
84478 - Triglycerides. The NCD refers only to diagnostic lipid testing for patients with a diagnosis or signs or symptoms of disease - not for screening non-symptomatic patients.
Diagnosis coding for hyperlipidemia can be complicated. The two primary codes are 272.2 (Mixed hyperlipidemia) and 272.4 (Other and unspecified hyperlipidemia). The former involves elevated blood lipoproteins due to an inherited metabolic disorder. Without more definitive information, you should report unspecified hyperlipidemia as 272.4.
But don't settle for this code too quickly. You should code the diagnosis and treatment of hyperlipidemia to the highest level of specificity. Be sure to read all documentation and, if you have to, ask the physician for the detailed information necessary to choose the proper code. The patient might actually have hypertriglyceridemia (272.1) or familial hypercholesterolemia (272.0). Although Medicare's lipid NCD covers testing for all codes 272.x (Disorders of lipoid metabolism), you must accurately code the condition to the fourth digit.
Frequency limits: For patients on anti-lipid dietary or drug-management therapy, Medicare's NCD states that "it may be reasonable to perform the lipid panel annually ... while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia."
For monitoring hyperlipidemia therapy, the NCD goes on to state that any one component of the panel or a measured LDL may be reasonable and necessary up to six times the first year. Changes in therapy or marked lipid elevation may indicate medical necessity for more frequent total cholesterol, HDL cholesterol, LDL cholesterol and triglyceride testing. "The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved," according to the NCD.
