Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

MA PPO Host - Claim Payment Policy Bulletin

Title:

Reimbursement for Components of Comprehensive Laboratory Panels

Policy #:

MA01.006a

Policy

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.

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

2022 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 April 4, 2022.

Centers for Medicare and Medicaid Services (CMS). National Correct Coding Initiative's (NCCI) General Correspondence Language and Section-Specific Examples. Effective January 1, 2022. Available at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd. Accessed April 4, 2022

Coding

CPT Procedure Code Number(s)

See Attachment A.

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

N/A

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

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

Policy History

Revisions From MA01.006a:

05/04/2022	This policy has been reissued in accordance with the Company's annual review process.
06/15/2020	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.

Revisions From MA01.006:

03/06/2015

This is a new policy.

Version Effective Date:

06/15/2020

Version Issued Date: