Organ and Disease Panels - HCA Healthcare



| SCOPE: All Company-affiliated hospitals performing and/or billing laboratory services. Specifically, the following departments: |

| |

|Business Office Nursing |

|Admitting/Registration Laboratory |

|Administration Case Management |

|Revenue Integrity Shared Services Centers |

|Health Information Management |

|Reimbursement |

|PURPOSE: To establish guidelines for billing Organ and Disease panels in accordance with Medicare, Medicaid, and other federally-funded payer |

|requirements. |

|POLICY: Organ and Disease panels and component tests billed to a federally-funded program must be based on a written order and be medically |

|necessary. Only the Centers for Medicare and Medicaid Services (CMS)-approved Organ and Disease panels will be billed at the panel level to |

|Medicare, Medicaid and other federally-funded payers, unless the payer has provided written documentation regarding the acceptance of other American|

|Medical Association defined Organ and Disease panels. Chemistry components will be bundled to the panel level when all of the tests in the panel |

|are ordered and performed. |

| |

|Repeated laboratory tests, including repeated components of panels, may be billed when the tests are medically necessary, which is indicated by |

|reporting modifier 91. Modifier 91 may only be reported when in the course of treating a patient, it is necessary to repeat the same laboratory |

|test on the same day to obtain subsequent test results. This modifier may not be reported when tests are rerun to confirm initial results; due to |

|testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This |

|modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). If a|

|payer does not recognize or accept modifier 91 and the payer has not provided you with their specific billing guidance for repeated laboratory |

|tests, these tests may not be billed. |

| |

|If a CPT code is a component of a CMS-approved Organ and Disease panel, a subsequent test performed on a different specimen type may be billed when |

|medically necessary, which is indicated by reporting modifier 59. If a payer does not recognize or accept modifier 59 and the payer has not |

|provided you with their specific billing guidance for repeated laboratory tests, these tests may not be billed. |

| |

|CMS has established Medically Unlikely Edits (MUE) and National Correct Coding Initiative (NCCI) edits. MUEs may trigger when units of service on a |

|given claim line item exceed the established limit for that HCPCS code. NCCI edits may trigger when there are restrictions on code combinations |

|reported on a single date of service. MUEs and/or NCCI edits may supersede information within this policy. |

|PROCEDURE: The following steps must be performed when billing Organ and Disease panels to Medicare, Medicaid, and other federally-funded programs. |

| |

|IMPLEMENTATION |

|Assign CPT/HCPCS codes and revenue codes for each panel and panel component test in accordance with the Company Standard Laboratory Chargemaster. |

|Set-up the Laboratory and Order Entry dictionaries or masterfiles to enable the ordering and billing of panels. |

| |

|80047 Basic Metabolic Panel (Calcium, Ionized) National Limit Amount $11.91 |

|Revenue Code 301 |

|Calcium, ionized (82330) |

|Carbon dioxide (82374) |

|Chloride (82435) |

|Creatinine (82565) |

|Glucose (82947) |

|Potassium (84132) |

|Sodium (84295) |

|Urea Nitrogen (BUN) (84520) |

| |

|80048 Basic Metabolic Panel (Calcium, Total) National Limit Amount $11.91 |

|Revenue Code 301 |

|Calcium, total (82310) |

|Carbon dioxide (82374) |

|Chloride (82435) |

|Creatinine (82565) |

|Glucose (82947) |

|Potassium (84132) |

|Sodium (84295) |

|Urea nitrogen (BUN) (84520) |

| |

|80051 Electrolyte Panel National Limit Amount $ 9.87 |

|Revenue Code 301 |

|Carbon dioxide (82374) |

|Chloride (82435) |

|Potassium (84132) |

|Sodium (84295) |

| |

|80053 Comprehensive Metabolic Panel National Limit Amount $14.87 |

|Revenue Code 301 |

|Albumin (82040) |

|Bilirubin, total (82247) |

|Calcium, total (82310) |

|Carbon dioxide (82374) |

|Chloride (82435) |

|Creatinine (82565) |

|Glucose (82947) |

|Phosphatase, alkaline (84075) |

|Potassium (84132) |

|Protein, total (84155) |

|Sodium (84295) |

|Transferase, alanine amino (ALT),(SGPT) (84460) |

|Transferase, aspartate amino (AST) (SGOT) (84450) |

|Urea nitrogen (BUN) (84520) |

| |

|80061 Lipid Panel National Limit Amount - None |

|Revenue Code 301 State Range: Low: $11.83 High: $14.87 |

|Cholesterol, serum, total (82465) |

|Lipoprotein, direct measurement, |

|high density cholesterol |

|(HDL cholesterol) (83718) |

|Triglycerides (84478) |

| |

|80069 Renal Function Panel National Limit Amount $12.22 |

|Revenue Code 301 |

|Albumin (82040) |

|Calcium; total (82310) |

|Carbon dioxide (82374) |

|Chloride (82435) |

|Creatinine (82565) |

|Glucose (82947) |

|Phosphorus inorganic (phosphate) (84100) |

|Potassium (84132) |

|Sodium (84295) |

|Urea nitrogen (BUN) (84520) |

| |

|80074 Acute Hepatitis Panel National Limit Amount – None |

|Revenue Code 300 State Range: Low: $57.92 High: $67.01 |

|Hepatitis A antibody (HAAb), IgM antibody (86709) |

|Hepatitis B core antibody (HBcAb), IgM antibody (86705) |

|Hepatitis B surface antigen (HBsAg) (87340) |

|Hepatitis C antibody (86803) |

| |

|80076 Hepatic Function Panel National Limit Amount $11.49 |

|Revenue Code 301 |

|Albumin (82040) |

|Bilirubin; total (82247) |

|Bilirubin; direct (82248) |

|Phosphatase, alkaline (84075) |

|Protein, total (84155) |

|Transferase, aspartate amino (AST) (SGOT) (84450) |

|Transferase, alanine amino (ALT) (SGPT) (84460) |

| |

|Business Office or Service Center personnel must verify that edits are present in the electronic billing system which: |

|Bundle individual component tests to the most comprehensive panel level as defined in this procedure. |

|Compare individual component tests within each panel to any component tests not billed as part of a panel and identify repeated tests. |

|Compare individual component tests of multiple panels and identify duplicate components. |

| |

|Laboratory and Business Office/Service Center personnel must educate all staff associates responsible for ordering, charging, or billing laboratory |

|services regarding the requirements of this policy. |

| |

|Monitoring activities must be completed in accordance with the Billing – Monitoring Policy, REGS.GEN.001. |

| |

|DAILY |

|It is recommended but not required that laboratory personnel review daily charge reports (e.g., Ancillary Charge Report, NPR charge reports, etc.) |

|to verify compliance with this policy as follows: |

|Bundle individual component tests to the most comprehensive panel level as defined in this procedure. |

|Compare individual component tests within each panel to any component tests not billed as part of a panel and identify repeated tests. |

|Compare individual component tests of multiple panels and edit for duplicate components. |

| |

|Service Center or Business Office personnel must review electronic billing edit/error reports daily and perform the following: |

|Bundle chemistry components to the appropriate comprehensive panel. |

|Identify the presence of repeated panels and component tests and determine if documentation is present to support medical necessity. |

|Append the appropriate modifier (59 or 91) to repeated tests or panels which are medically necessary. |

|Eliminate repeated tests or panels which are not medically necessary. Modify number of units and related charges in the electronic billing vendor |

|system to reflect the appropriate charge for the panel being billed. |

| |

| |

|The Facility Ethics and Compliance Committee is responsible for implementation of this policy within the facility. |

|REFERENCES: |

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|Medicare Claims Processing Manual, Chapter 16, Section 90 |

|AMA CPT Assistant, Summer 1993 Pages: 14-15 |

|AMA CPT Assistant, January 1998 Pages: 7-8 |

|American Medical Association Physicians’ Current Procedural Terminology CPT |

|Current Year Clinical Lab Fee Schedule |

|CMS website - National Correct Coding Initiative edits |

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