Medicare CPT 80061, 82465, 83718 & 84478

Cardiovascular Screening Blood Tests

Every year, thousands of Americans die of heart disease and stroke. Millions more currently live with one or more types of cardiovascular disease, including, coronary heart disease, stroke, high blood pressure, congestive heart failure, congenital cardiovascular defects, and hardening of the arteries. Heart disease and stroke are also among the leading causes of disability for both men and women in the United States.

Recognizing the need for early detection to effectively combat the risks of cardiovascular disease, Congress expanded preventive services to include the coverage of cardiovascular screening blood tests. Section 612 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 established Medicare coverage of cardiovascular screening blood tests.


The cardiovascular screening blood tests covered by Medicare include the following:

Total Cholesterol Test
Cholesterol Test for High Density Lipoproteins
Triglycerides Test

NOTE: The beneficiary must fast for 12 hours prior to testing. Other cardiovascular screening blood tests remain non-covered .


CPT Codes for Cardiovascular Screening Blood Tests

80061 - Lipid Panel This panel must include the following:Cholesterol, serum, total (82465)Lipoprotein, direct measurement, high density cholesterol (HDLcholesterol) (83718)Triglycerides (84478)

82465 - Cholesterol, serum or whole blood, total (For high density lipoprotein HDL,use 83718)

83718 - Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)

84478 - Triglycerides


80061 Lipid panel

A lipid panel includes the following tests: total serum cholesterol (82465), high–density cholesterol (HDLcholesterol) by direct measurement (83718), and triglycerides (84478). Blood specimen is obtained by venipuncture. See specific codes for additional  information about the listed tests.

ICD 10 CODE

Z00.00, Z00.01, Z13.220

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


Diagnosis covered

Medicare providers must report one or more of the following International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) screening ("V") diagnosis code(s) for cardiovascular screening blood tests:

V81.0 Special screening for ischemic heart disease
V81.1 Special screening for hypertension
V81.2 Special screening for other and unspecified cardiovascular conditions


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.


POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

To monitor the progress of patients on anti-lipid dietary management and pharmacologic therapy for the treatment of elevated blood lipid disorders, total cholesterol, HDL cholesterol and LDL cholesterol may be used. Triglycerides may be obtained if this lipid fraction is also elevated or if the patient is put on drugs (for example, thiazide diuretics, beta-blockers, estrogens, glucocorticoids, and tamoxifen) which may raise the triglyceride level.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B.  appropriate with regard to standards of good medical practice; and
C.  not solely for the convenience of the Member, his or her Provider; and
D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.


Coding Automated Tests

Tests on Medicare’s list of automated procedures may be billed using any combination of automated test panel codes or individual automated test codes (Medicare Claims Processing Manual, Chapter 16, Section 90). Under this policy it is virtually impossible to improperly unbundle automated multichannel test panels. Medicare carriers will accept any combination of individual tests and panels that contain automated, multichannel tests, and pay the appropriate amount for the total number of tests submitted. However, the CPT® notes that the Basic Metabolic Panel is not to be reported in addition to a Comprehensive Metabolic Panel or a Hepatic Function Panel.

For example, a lipid panel plus AST and ALT can either be reported as 80061 (lipid panel) plus 84450 (AST) and 84460 (ALT) or as 82465 (total cholesterol), 84478 (triglycerides), 83718 (HDL cholesterol), 84450 (AST) and 84460 (ALT).


1 CPT code 83718 is billed with Organ/Disease Panel 80061 but is not included in the AMCC bundling..


Blood Test screening

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. 


GroupName

CPT code 80061 Lipid panel must include procedures 82465, 83718, 84478.

*Claims for VLDL (83719) and lipoprotein (a)(82172) will be denied as not medical 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.

84478 TRIGLYCERIDES

*ICD-9-CM codes V81.0, V81.1 and V81.2 are only payable for CPT codes 80061, 82465, 83718 and 84478.


Source: Program Memorandum AB-02-110, Effective 11-25-02; Medicare NCD Manual, July 2003 Release; Medicare NCD Manual, October 2003 Release, January 2004 Release, October 2004 Release, January 2005 Release, October 2005 Release, April 2006 Release; July 2006 Release, October 2006 Release, January 2009 Release, April 2009 Release, October 2010 Release

CMS (Medicare) has determined that Lipid Testing (CPT Codes 80061, 82465, 83700, 83701, 83704, 83718, 83721, 84478) is only medically necessary and, therefore, reimbursable by Medicare when ordered for patients with any of the diagnostic conditions listed below in the “ICD-9-CM Codes Covered by Medicare Program.” If you are ordering this test for a diagnostic condition other than those listed below, please have your patient sign and date an Advanced Beneficiary Notice (ABN). All ICD-9-CM codes provided must be consistent with the documentation in the patient’s medical records for the date of service.

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