MA PPO

Reimbursement for Components of Comprehensive Laboratory Panels
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

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

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


Coding and Billing Requirements



Policy History

6/15/2020
6/15/2020
MA01.006
Claim Payment Policy Bulletin
Medicare Advantage
{"1827":{"Id":1827,"MPAttachmentLetter":"A","Title":"CPT Codes","MPPolicyAttachmentInternalSourceId":0,"PolicyAttachmentPageName":"EEF7B1B6F23D48E8852585880062ACAF"},}
Yes