Notification

Reimbursement for Components of Comprehensive Laboratory Panels


Notification Issue Date: 05/15/2020

This version of the policy will become effective 06/15/2020.

The following CPT code has been added to Attachment A in this policy: 80081.



Medicare Advantage Policy

Title:Reimbursement for Components of Comprehensive Laboratory Panels
Policy #:MA01.006a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

This policy applies to providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, as well as outpatient facilities billing on a UB-04 claim form or the electronic equivalent, 837i, for members enrolled in all Company products.

Depending on the laboratory test, when a certain number of individual component laboratory procedure codes are reported together and performed by the same professional provider or professional providers in the same group, or by the same facility healthcare system, on the same individual, and on the same date of service in all places of service, the component procedure codes will be combined into the procedure code that represents the most closely related comprehensive laboratory panel, and reimbursement will be made for the comprehensive laboratory panel.

This policy applies to the following comprehensive laboratory panels:
  • Basic metabolic panel (Current Procedural Terminology [CPT] codes 80047, 80048)
  • General health panel (CPT code 80050)
  • Electrolyte panel (CPT code 80051)
  • Comprehensive metabolic panel (CPT code 80053)
  • Obstetric panel (CPT code 80055)
  • Lipid panel (CPT code 80061)
  • Renal function panel (CPT code 80069)
  • Acute hepatitis panel (CPT code 80074)
  • Hepatic function panel (CPT code 80076)
  • Obstetric panel (includes HIV testing) (CPT code 80081)

Refer to Attachment A of this policy for the component laboratory procedure codes that are reimbursed as part of the more comprehensive laboratory panel procedure code.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Policy Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the Evidence of Coverage, laboratory tests are covered under the medical benefits of the Company's Medicare Advantage products.

This claim payment rationale applies only to the services addressed in this policy and does not apply to any other codes. Claims are processed according to the statements in this policy. When a medical policy on this topic also exists, the medical necessity criteria listed in the medical policy must be met.

Company network and capitation rules will continue to apply to the services identified in this policy.

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Description

Individual laboratory tests are often ordered and performed as a comprehensive laboratory panel. The American Medical Association (AMA) defines the components of numerous organ or disease-oriented laboratory panels for coding purposes.
References

2020 AMA CPT Procedural Manual.

Centers for Medicare and Medicaid Services (CMS). Medicare Claims Processing Manual Chapter 12 - Physicians/Nonphysician Practitioners. Section 30k. Available at: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf. Accessed March 6, 2020.

Centers for Medicare and Medicaid Services (CMS). National Correct Coding Initiative's (NCCI) General Correspondence Language and Section-Specific Examples. Effective April 1, 2019. Available at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd
Accessed March 6, 2020.


Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

See Attachment A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Reimbursement for Components of Comprehensive Laboratory Panels
Description: CPT Codes







Policy History

MA01.006a
06/15/2020This version of the policy will become effective 06/15/2020.

The following CPT code has been added to Attachment A in this policy: 80081.

MA01.006
03/06/2015This is a new policy.




Version Effective Date: 06/15/2020
Version Issued Date: 06/15/2020
Version Reissued Date: N/A