Wiki Labs - currently paying for CPT code

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bchavez7

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I work for an insurance company and they are currently paying for CPT code 80076 and 80050. 80076 has components that are within 80053 which is part of 80050. We follow CMS guidelines and CCI does not bundle 80050 and 80076 but does bundle 80053 and 80076. Can someone tell me if they have any guidelines statinf 80076 is inclusive to 80050.
thanks for your help!
 
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Found this online in regards to what tests are included in certain panels. You mentioned "currently paying for CPT code 80076 and 80050" I can see that this would be correct because neither of these panels have the same tests within being performed.

You also mentioned, "80076 has components that are within 80053 which is part of 80050." This is incorrect. 80076 does have many of the same tests in 80053 which is why only the reimbursement for 80053 will be paid and 80076 will be denied. The note below the 80076 below says that reimbursement will not exceeed the 80053 since its the larger panel of tests between the two.

Finally, "We follow CMS guidelines and CCI does not bundle 80050 and 80076 but does bundle 80053 and 80076. Can someone tell me if they have any guidelines statinf 80076 is inclusive to 80050?" CCI is correct not to bundle 80050 and 80076 because the tests are completely unique in each panel and do not duplicate. As mentioned above before teh 80076 and 80050 would not be inclusive as they are two seperate panels with no duplicating tests within. I added the CPT below the test names to show a quick reference as to see duplicated tests more clearly. Hopefully this "cheat of labs" will help you determine proper reimbursement.

80053 - Comprehensive Metabolic Panel (CPT: 80053) 3mL Serum
Includes: (14 tests)
• Urea Nitrogen, Blood (BUN)(84520)
• Protein, Total (84155) except by refractometry; serum
• Potassium, Serum(84132)
• SGOT (AST)(84450) – Transferase, aspirate amino
• Bilirubin, Total (82247)
• Chloride, Serum, blood(82435)
• CO2 (bicarbonate)(82374) Carbon Dioxide
• Creatinine, Serum, blood (82565)
• Alkaline Phosphatase (84075)
• ALT (SGPT) (84460) – Transferase, alanine amino)
• Calcium, Total (82310)
• Glucose, Fasting, Quantitive (82947)
• Sodium, Serum (84295)
• Albumin; serum (82040)

Note: If both codes 80048 (basic metabolic panel) and 80053 (comprehensive metabolic panel) are billed by the same provider for the same recipient and date of service, reimbursement will not exceed payment for the comprehensive metabolic panel.

80050 – General Health Panel (CPT: 80050) 3mL Serum
Includes: (2 tests)
• CBC (Complete Blood Count) (85025)
• TSH, Ultra Sensitive – Thyroid Stimulating Hormone(84443)

80076 - Hepatic Function Panel (CPT:80076) 2mL Serum
Includes: (7 tests)
• Bilirubin, Direct (82248)
• Protein, Total-except by refractometry; serum (84155)
• SGOT (AST)(84450) – Transferase, aspirate amino
• Bilirubin, Total (82247)
• Alkaline Phosphatase (84075)
• ALT (SGPT) (84460) – Transferase, alanine amino
• Albumin; serum (82040)

Note: If both codes 80076 (hepatic function panel) and 80053 (comprehensive metabolic panel) are billed by the same provider for the same recipient and date of service, reimbursement will not exceed payment for the comprehensive metabolic panel.
 
Yes but per CPT 80050 includes a CBC-85025 and TSH-84443 as well as panel 80053, therefore 80076 should not be billed with lab panel 80050 as it has 80053 within it...correct?
 
80053 and 80048

CCI edits state you can't code 80053 and 80048 together and a modifier is not allowed ever. Is this based on date of service? What if the visit is over a 2 day period and each test is on a different date, does this change at all or is the edit cut and dry and they can't be used at all on the claim?
 
tlccovert said:
CCI edits state you can't code 80053 and 80048 together and a modifier is not allowed ever. Is this based on date of service? What if the visit is over a 2 day period and each test is on a different date, does this change at all or is the edit cut and dry and they can't be used at all on the claim?
Click to expand...

If the blood was drawn on 2 different days then yes you can bill them with 2 different dates of service. You cant, say hold off on analyzing the blood to separate days in order to get around CCI edits.
 
would you attach a modifier in this case or should it not hit an edit if it has 2 different DOS say 80053-2/1/13 and 80048-2/2/13. will it not hit edit if correct dates are attached or if it has correct dates do we attach modifier even though it says modifier not allowed? What if there are 2 different blood draws on the same DOS?

Thanks again. I am new to working the CCI edits on lab encounters
 
tlccovert said:
would you attach a modifier in this case or should it not hit an edit if it has 2 different DOS say 80053-2/1/13 and 80048-2/2/13. will it not hit edit if correct dates are attached or if it has correct dates do we attach modifier even though it says modifier not allowed? What if there are 2 different blood draws on the same DOS?

Thanks again. I am new to working the CCI edits on lab encounters
Click to expand...

As long as they are not done on the same DOS they are fine to bill on the same form. Hope that helps!
 
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