Claim Review on HCPCS CPT 80053 and 36415

80053: Comprehensive metabolic panel

Effective for dates of service on and after January 1, 2012, A/B MACs (B) shall allow organ disease panel codes (i.e., HCPCS codes 80047, 80048, 80051, 80053, 80061, 80069, and 80076) to be billed by independent laboratories for AMCC panel tests furnished to ESRD eligible beneficiaries if: • The beneficiary is not receiving dialysis treatment for any reason (e.g., posttransplant beneficiaries), or

• The test is not related to the treatment of ESRD, in which case the supplier would append modifier “AY”.

Effective for dates of service on and after April 1, 2015, A/B MACs (A) shall allow organ disease panel codes (i.e., HCPCS codes 80047, 80048, 80051, 80053, 80061,
80069, and 80076) to be billed by ESRD facilities for AMCC panel tests furnished to ESRD eligible beneficiaries if:

• These codes best describe the laboratory services provided to the beneficiary, which are paid under the ESRD PPS, or

• The test is not related to the treatment of ESRD, in which case the ESRD facility would append modifier “AY” and the service may be paid separately from the ESRD PPS.

The organ and disease oriented panels (80048, 80051, 80053, and 80076) are subject to the 50 percent rule. However, clinical diagnostic laboratories shall not bill these services as panels, they must be billed individually. Laboratory tests that are not covered under  the composite rate and that are furnished to CAPD end stage renal disease (ESRD) patients dialyzing at home are billed in the same way as any other test furnished home patients.

“Do not  report two or more panel codes that include any of the same constituent tests performed from the same patient collection. If a group of tests overlaps two or more panels, report the panel that incorporates the greater number of tests to fulfill the code definition and report the remaining tests using individual test codes (e.g., do not report 80047 in conjunction with 80053).”

Based on the new information from CPT, UnitedHealthcare’s Laboratory Rebundling Policy will no longer consider the submission of CPT 80048- Basic Metabolic Panel plus CPT 80076-Hepatic Function Panel as reason to bundle to the Comprehensive Metabolic Panel code, CPT 80053.


However, should the same physician and/or other health care professional report CPT 80053 with CPT 80048 or CPT 80076 for the same patient on the same date of service, CPT 80048 or CPT 80076 will not be reimbursed separately. This also aligns with CPT coding guidance. CPT panel code 80053 includes all of the components of CPT panel code 80048 and all the components of CPT panel code 80076, except for CPT 82248. Therefore, the charges for CPT 82248 should be submitted separately when performed with CPT 80053 for the same date of service



New Jersey Claim Review on HCPCS 80053 and 36415

In an effort to safeguard the Medicare Trust Fund by lowering the Comprehensive Error Rate Testing (CERT) paid claims error rate, Highmark Medicare Services’ Medical Review Department performs reviews and provides education based on data analysis performed to identify problem areas.  The CERT program is the driver of this data analysis.  The Centers for Medicare and Medicaid Services (CMS) and Highmark Medicare Services uses the information from the CERT error rate findings to determine the underlying reasons for claim errors and develops appropriate action plans to improve compliance in payment, claims processing, and provider billing practices.

Recent CERT data analysis indicated that there were multiple claim errors in New Jersey for procedure code 80053, Comprehensive Metabolic Panel, and procedure code 36415, Venipuncture.

As a result of this data analysis, Highmark Medicare Services’ Medical Review Department conducted a widespread post payment edit in New Jersey on procedure codes 80053 and 36415.


Our findings indicated that approximately 48% of the claims sampled were billed incorrectly.  The majority of the denials were based on the following:

     Physician orders were not signed and dated.
     No documentation in the medical record to indicate that the physician ordered the test.


As a result of these edit findings, and to reduce the overall claims payment error rate, a
prepayment edit will be implemented on procedure codes 80053 and 36415 for New Jersey providers.


Medical records will be requested to verify that services billed were rendered, medically necessary, adequately documented, and billed appropriately to the Medicare program.  If the requested medical record documentation is not made available upon request to support services billed, the service may be denied.

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