Frequency of Laboratory Tests - CPT 80061, 82465, 82948, 82962, 84479

CPT  code and description

80061 - Lipid panel

This panel must include the following:

Cholesterol, serum, total (82465)
Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718)
Triglycerides (84478)


82962 Glucose blood test - 0.00

LIPID TESTING (CPT 80061, 82465, 83695, 83698, 83700, 83704, 83718, 83719, 83721, 84478)

ICD-10 Description ICD-10 ICD-9

Heart Failure, Unspecified I50.9 428
Hyperlipidemia, Unspecified E78.5 272.4
Hyperlipidemia, Unspecified E78.5 272.4
Hypertensive Heart and Chronic Kidney Disease without Heart Failure, with Stage 1 through Stage 4 Chronic Kidney Disease I13.10 404.91
Unspecified Chronic Kidney Disease N18.9 585.9
Overweight E66.3 278.02 Pure Hypercholesterolemia E78.0 272
Type 2 Diabetes Mellitus without Complications E11.9 250


Please note there are some specific relevant Medicare requirements with respect to glucose monitoring. Medicare Part B may pay for a glucose monitoring device and related disposable supplies under its durable medical equipment benefit if the equipment is used in the home or in an institution that is used as a home. A hospital or Skilled Nursing Facility (SNF) is not considered a home under this benefit (Section 1861(h) of the Social Security Act, 42 CFR 410.38). Routine glucose monitoring of diabetics is never covered in an SNF, whether the beneficiary is in a covered Part A stay or not. Glucose monitoring may only be covered when it meets all the conditions of a covered laboratory service, including use by the physician in modifying the patient’s treatment.

The following are the pertinent laboratory tests for which frequency limitations will be specified, noting that lipid, thyroid and glucose testing frequencies apply to analytes from the laboratory National Coverage Determination (NCD) via negotiated rulemaking:

  • Lipids.
  • Thyroid testing.
  • Glucose testing.
  •  
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
To be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.



Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.


CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.

80061©
Lipid panel
82465©
Assay, bld/serum cholesterol
82948©
Reagent strip/blood glucose
82962©
Glucose blood test
83718©
Assay of lipoprotein
83721©
Assay of blood lipoprotein
84436©
Assay of total thyroxine
84439©
Assay of free thyroxine
84443©
Assay thyroid stim hormone
84478©
Assay of triglycerides
84479©
Assay of thyroid (t3 or t4)

Limitations

Tests not ordered by a treating physician will be denied as not medically necessary.
Claims for VLDL (83719) and lipoprotein (a) (82172) will be denied as not medically necessary, since NCEP recommendations do not include monitoring of VLDL or apolipoprotein levels for treatment of elevated cholesterol as risk factors for coronary and vascular atherosclerosis.

Once a diagnosis is established, one or several specific tests are usually adequate for monitoring the course of the disease. Less specific diagnoses (for example, other chest pain) alone do not support medical necessity of these tests.
If no dietary or pharmacological therapy is advised, monitoring is not necessary and will be denied.

When evaluating non specific chronic abnormalities of the liver (for example, elevations of transaminase, alkaline phosphatase, abnormal imaging studies, etc.), a lipid panel would generally not be indicated more than twice per year.


When monitoring serum LDL levels, it is usually not necessary to obtain a lipid panel 80061 (total cholesterol, HDL and triglycerides) and a measured LDL-cholesterol (83721) on the same day, unless the serum triglyceride level is greater than 400mg/dl. Consequently, if requested on the same day as a lipid panel, the measured LDL should only be ordered as a reflex test, to be performed if the triglycerides exceed this value.


ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 80061, 82465, 82948, 82962, 83718, 83721, 84436, 84439, 84443, 84478 and 84479:

Covered for:
Refer to the NCDs for the procedure code list of ICD-9-CM codes that do not support medical necessity at:

Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.

Coding and Billing Guide

All these CPT Required  CLIA Certification QW Modifier

UnitedHealthcare Community Plan reimburses for Lipids Testing (CPT codes 80061, 83700, 83701, 83704, 83718, 83721, and 84478), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-9-CM and ICD-10-CM diagnostic codes being included on  the claim accurately reflecting the member's condition.


80061 Lipid panel

A lipid panel includes the following tests: total serum cholesterol (82465), high–density cholesterol (HDL cholesterol) by direct measurement (83718), and triglycerides (84478). Blood specimen is obtained by venipuncture.

There may be limited circumstances when the column two code is separately reportable with the column one code. For example, the NCCI has an edit with column one CPT code of 80061 (lipid profile) and column two CPT code of 83721 (LDL  cholesterol by direct measurement). If the triglyceride level is less than 400 mg/dl, the LDL is a calculated value utilizing the results from the lipid profile for the calculation, and CPT code 83721 is not separately reportable. However, if the triglyceride level is greater than 400 mg/dl, the LDL may be measured directly and may be separately reportable with CPT code 83721 utilizing an NCCIassociated modifier to bypass the edit.


Diagnostic Lipid Testing

A lipid panel or any component of the panel may be considered medically necessary for evaluating atherosclerotic cardiovascular disease for patients meeting any of the following criteria:

As follow-up to the initial screen for coronary heart disease (total cholesterol + HDL cholesterol) when total cholesterol is determined to be high (>240 mg/dL), or borderline-high (200-240 mg/dL) plus two or more coronary heart disease risk factors, or an HDL cholesterol <35 dl.="" mg="" p="">When monitoring serum LDL levels, it is usually not necessary to obtain a lipid panel (80061) and a measured LDL-cholesterol (83721) on the same day, unless the serum triglyceride level is greater than 400mg/dl. Consequently, if requested on the same day as a lipid panel, the measured LDL is only considered medically necessary if ordered as a reflex test, to be performed if the triglycerides exceed this value.

Assessment of patients with atherosclerotic cardiovascular disease Diagnostic evaluation of diseases associated with altered lipid metabolism, such as: nephrotic syndrome, pancreatitis, hepatic disease, and hypothyroidism, and hyperthyroidism Secondary dyslipidemia, including diabetes mellitus, disorders of gastrointestinal absorption, chronic renal failure  Signs or symptoms of dyslipidemias, such as skin lesions

For patients with severe psoriasis which has not responded to conventional therapy and for which the retinoid etretinate has been prescribed and who have developed hyperlipidemia or hepatic toxicity. Specific examples include erythrodermia and generalized pustular type and psoriasis associated with arthritis.

A diagnostic lipid panel or any component of the panel may be considered medically necessary up to three (3) times per calendar year for monitoring dietary or pharmacologic therapy.

If no dietary or pharmacological therapy is advised, monitoring is considered not medically necessary.

UHC Military Veterans - Preventive Lipid Panels, CPT 80061, are only covered once every five years.

CPT 80061 will not reimbursed with following codes

80500 80502 82465 83718 83721 84478
<35 dl.="" mg="" p="">
<35 dl.="" mg="" p="">
MEDICARE LIMITATIONS AND GUIDELINES:

When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it is reasonable to perform the lipid panel annually. A lipid panel (CPT code 80061) at a yearly interval will usually be adequate while measurement of the serum total cholesterol (CPT code 82465) or a measured LDL (CPT code 83721) should suffice for interim visits if the patient does not have hypertriglyceridemia (for example, ICD-9-CM code 272.1, Pure hyperglyceridemia).

Any one component of the panel or a measured LDL may be medically necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDLcholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved. If no dietary or pharmacological therapy is advised, monitoring is not necessary.

When evaluating non-specific chronic abnormalities of the liver (for example, elevations of transaminase, alkaline phosphates, abnormal imaging studies, etc.), a lipid panel would generally not be indicated more  Than twice per year.
<35 dl.="" mg="" p="">
Utilization Guidelines
Please note the following guidelines only apply to diagnostic laboratory testing. Frequency parameters, and other program requirements, for similar laboratory testing under the Cardiovascular Disease Screening program, can be found in Medicare Part A Newsletter No. 01-2005, dated January 31, 2005 and in Medicare Part B Newsletter No. 05-050, dated March 1, 2005.

The table below summarizes certain frequencies beyond which Medicare would consider further tests neither reasonable nor necessary. To support equitable implementation of such frequency limits, they will be applied on a “per-beneficiary, per-provider” basis to account for patients who may need to see different providers to best accommodate their needs. Certain tests may exceed the stated frequencies when accompanied by a diagnosis fitting the description in the column marked “Acceptable Reasons (ICD-9-CM Codes) for Exceeding the LCD Maximum.”



Cholesterol Screening (Lipid Disorders Screening)

Procedure Code(s): 80061, 82465, 83718, 83719, 83721, 84478, 36415, 36416 Diagnosis Code(s) (Required for all): V70.0 or V77.91 Diagnosis Code(s):

REQUIRED DIAGNOSIS CODES (required for all ages 20 and up): 

• ICD-9: V70.0 or V77.91
• ICD-10: Z00.00, Z00.01, Z13.220

AND

Additional Diagnosis Codes Required (required for age 20-34) :

FAMILY or PERSONAL HISTORY:

• ICD-9: V15.82, V17.3, V17.49

• ICD-10: Z72.0, Z82.49, Z87.891, F17.210, F17.211, F17.213, F17.218, F17.219 OBESITY:

• ICD-9: 278.00, 278.01

• ICD-10: E66.01, E66.09, E66.1, E66.8, E66.9

BODY MASS INDEX 40 AND OVER, ADULT:

• ICD-9: V85.41, V85.42, V85.43, V85.44, V85.45

• ICD-10: Z68.41, Z68.42, Z68.43, Z68.44, Z68.45

ESSENTIAL HYPERTENSION:

• ICD-9: 401.0, 401.1, 401.9

• ICD-10: I10

SECONDARY HYPERTENSION:

• ICD-9: 405.01, 405.09, 405.11, 405.19, 405.91, 405.99

• ICD-10: I15.0, I15.1, I15.2, I15.8, I15.9, N26.2

HYPERTENSION COMPLICATING PREGNANCY, CHILDBIRTH AND THE PUERPERIUM: 

• ICD-9: 642.01, 642.03, 642.04, 642.11, 642.13, 642.14, 642.21, 642.23, 642.24, 642.30, 642.31, 642.33, 642.34, 642.91, 642.93, 642.94

• ICD-10: O10.011, O10.012, O10.013, O10.019, O10.02, O10.03, O10.111, O10.112, O10.113, O10.119, O10.12, O10.13, O10.211, O10.212, O10.213, O10.219, O10.22, O10.23, O10.311, O10.312, O10.313, O10.319, O10.32, O10.33, O10.411, O10.412, O10.413, O10.419, O10.42, O10.43, O10.911, O10.912, O10.913, O10.919, O10.92, O10.93, O11.1, O11.2, O11.3, O11.9, O13.1, O13.2, O13.3, O13.9, O16.1, O16.2, O16.3, O16.9 Age 35 and up.


Age 20-34 if at increased risk for coronary heart disease. NOTE: These will only pay as preventive if there is no prior history of a lipid disorder.


Type of Lab Test (CPT Code)
LCD Frequency Limit (Per-Beneficiary, Per-Provider)
Acceptable Reasons (ICD-9-CM Codes) for Exceeding the LCD Maximum
Lipids:
  • 80061.
  • 82465.
  • 83718.
  • 83721.
  • 84478.
No more frequently than every two months for any test (e.g., triglycerides, LDL cholesterol), whether in a panel or separately ordered.
  • Inability to stabilize lipid-lowering drug dosing (V58.69).
  • Adverse reaction to lipid-lowering drug (V58.69).
  • Pancreatitis (577.0–577.1).
Thyroid Testing:
  • 84436.
  • 84439.
  • 84443.
  • 84479.
Four times a year for most persons, except for selected endocrine presentations.
  • Inability to stabilize thyroid medication dosing.
  • Thyrotoxicosis.
  • Concurrent endocrinopathies.
  • Hypothyroidism.
(Codes pertaining to above bullets: 226, 242.00–242.91, 243, 244.0–244.3, 244.8–244.9, 245.0–245.4, 245.8–245.9, 250.00–250.03, 250.10–250.13, 250.20–250.23, 250.30–250.33, 250.40–250.43, 250.50–250.53, 250.60–250.63, 250.70–250.73, 250.80–250.83, 250.90–250.93, 252.1, 253.2, 253.4, 255.2, 255.4, 272.0, 272.2, 275.40–275.42, 275.49, 276.0–276.1, 279.4, 281.0, 281.9, 285.9, 290.0, 290.10–290.13, 290.20–290.21, 290.3, 293.0–293.1, 296.00–296.06, 296.10–296.16, 296.20–296.26, 296.30–296.36, 296.40–296.46, 296.50–296.56, 296.60–296.66, 296.7, 296.80–296.82, 296.89, 296.90, 296.99, 300.00–300.02, 300.09, 311, 359.5, 374.41, 374.82, 376.21–376.22, 427.0, 427.31, 428.0, 511.9, 560.1, 625.3, 750.15, 780.02, 780.09, 783.1, 783.21, 784.1, 785.0–785.1, 794.5, V58.69)
Glucose Testing:
  • 82948.
  • 82962.
(See “Other Comments” section of attached article for additional information.)
Once per month.
  • Uncontrolled diabetes mellitus (250.02–250.03, 250.92–250.93).


Notice: This LCD imposes utilization guideline limitations. Despite Medicare’s allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.


HCPCS/CPT Codes/Diagnosis Codes

The following HCPCS/CPT Codes are to be billed for the Cardiovascular Screening Blood Tests:

• 80061 Lipid Panel

• 82465 Cholesterol, serum, or whole blood, total

• 83718 Lipoprotein, direct measurement; high-density cholesterol

• 84478 Triglycerides (The tests should be performed as a panel; however, they are also available as individual tests.)

The following diagnosis codes must be submitted on the claim for when billing for cardiovascular screening blood test:

• V 81.0 Special Screening for ischemic heart disease

• V81.1 Special Screening for hypertension

• V81.2 Special Screening for other and unspecified cardiovascular conditions

Medicare will pay for cardiovascular disease screening under the Medicare Clinical Laboratory Fee Schedule. Providers and suppliers that bill for the cardiovascular disease screening benefit must point the screening diagnosis (V81.0, V81.1, V81.2) to the line item service. Other cardiovascular screening blood tests (for which CMS has not specifically indicated approval for national coverage) continue to be non-covered.




How Carriers and Intermediaries Will Treat Claims

Medicare carriers and intermediaries will treat claims as follows:

• Carriers/intermediaries will accept claims with HCPCS 80061 (Lipid Panel), 82465 (Cholesterol, serum or whole blood, total), 83718 (Lipoprotein, direct measurement; high density cholesterol, HDL Cholesterol), or 84478 (Triglycerides) when there is a reported diagnosis of V81.0 (Special screening for ischemic heart disease), V81.1 (Special screening for hypertension), or V81.2 (Special screening for other and unspecified cardiovascular conditions).

• Carriers/intermediaries will deny claims with code 80061 when there is already evidence of a paid claim within the prior 60 months that was billed with a diagnosis code of V81.0, V81.1, or V81.2, and with a procedure code of 80061, 82465, 83718, or 84478.


• Carriers/intermediaries will deny claims with procedure codes of 82465, 83718, or 84478 when billed within 60 months of a previous paid claim with a diagnosis code of V81.0, V81.1, 0r V81.2 and a procedure code of 80061.  

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