CPT code 80050, 80053 - General health panel, CBC AND WBC, CBS

 CPT code and description


80050 - General health panel


This panel must include the following: Comprehensive metabolic panel (80053), Blood count, complete (CBC), automated and automated differential WBC count (85025 or 85027 and 85004), OR, Blood count, complete (CBC), automated (85027) and appropriate manual differential WBC count (85007 or 85009), Thyroid stimulating hormone (TSH) (84443)

82435 - Chloride; blood

86910 - Blood typing, for paternity testing, per individual; ABO, Rh and MN

86911 - Blood typing, for paternity testing, per individual; each additional antigen system

P2031 - HAIR ANALYSIS (EXCLUDING ARSENIC)


80053 - Comprehensive metabolic panel  - Average fee amount $17- $25

This panel must include the following:

Albumin (82040)
Bilirubin, total (82247)
Calcium, total (82310)
Carbon dioxide (bicarbonate) (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)

Medicare payment Guidelines.

80050 General health panel - Not payable by Medicare 310, 330, 400

In general, Medicare pays for items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body part.The statutory provisions for Medicare coverage found in section 1862 (a)(1)(A) of the Social Security Act, exclude from Medicare coverage “items and services that are not reasonable and necessary for the diagnosis of illness or injury or to improve the functioning of a malformed body member.”

"Not medically necessary" charges are those charges for services that the Medicare FI or carrier decides were not necessary or reasonable for the patient’s condition.

Concurrent hospital care during hospice (condition code 07), will be denied when the hospice diagnosis is:


Debility, ICD-9 code 799.3

Adult failure to thrive, ICD-9 code 783.7

Other general symptoms, ICD-9code 780.9


"Non-covered services" are services and procedures billed to the patient, not covered by Medicare, and are always denied either because:

A national decision to noncover the service/procedure exists, or

The service/procedure is included on the list of services determined by the contractor to be excluded from coverage

These non-covered services are charges that:

The beneficiary already knows are noncovered because they are included in the information given in the Medicare handbook (e.g., oral medications, screening mammograms in less than the designated waiting period, etc.)

They are considered either experimental or investigational in nature

They are routine physical examinations, for which Medicare does not pay under any circumstances because of statutory exclusions.

Medicare law places general and categorical limitations on services furnished by certain health care practitioners, such as dentists, chiropractors and podiatrists. The law specifically excludes from coverage such services as:

cosmetic surgery

personal comfort items

custodial care

routine physical checkups

services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury

Unless written notice of non-coverage is issued to the beneficiary prior to rendering a specific non-covered service, in some instances the provider may be held financially liable.

Providers are made aware of these non-covered items and services through updates to the Medicare Coverage Issues Manual, Medicare Carriers Manual, Medicare Hospital Manual, and other sources.

It is important to note that the fact that a new service or procedure has been issued a CPT code or is FDA approved does not, in itself, make the procedure "medically reasonable and necessary." It is our policy that new services, procedures, drugs, or technology must be evaluated and approved either nationally or by our local medical review policy process before they are considered Medicare covered services. Furthermore, national non-covered services may not be covered by local contractors.

This policy is initiated to list medical services and procedures that are never covered by the Medicare program.


General Health Panel, 80050

A submission that includes a Comprehensive Metabolic Panel, CPT code 80053, a Thyroid Stimulating Hormone, CPT code 84443 and one of the following CBC or combination of CBC Component Codes,  either CPT codes 85025 or 85027 + 85004 or 85027 + 85007 or 85025 + 85009 by the Same Individual Physician or Other Health Care Professional for the same patient on the same date of service is a reimbursable service as a General Health Panel, CPT code 80050

Exceptions

Iowa Iowa providers are allowed to bill 99000 for lab services.

Kansas Per Kansas State Regulations codes 84443, 85025, and 80053 can be billed separately and should not be denied into panel code 80050. Maryland Maryland allows payment of CPT 36416 when billed with an Evaluation and Management service.

Michigan Michigan follows CPT direction regarding panel codes and requires all components of a panel to be submitted; these codes will be denied and will need to be resubmitted with the corresponding panel code.

New Mexico Per New Mexico Medicaid State Regulations Drug Assay CPT codes 80320-80377 are considered non-reimbursable. These services may be reported under an appropriate HCPCS code.

Ohio Ohio follows CPT direction regarding panel codes and requires all components of a panel to be submitted; these codes will be denied and will need to be resubmitted with the corresponding panel code.

Ohio allows payment of CPT 36416 when billed with an Evaluation and Management service.

Per state requirements, Ohio Medicaid and MME plans require that certain lab codes cannot be submitted with a modifier. The list of codes is included in the policy.

Texas Texas allows reimbursement for CPT code 99000. Wisconsin Wisconsin allows payment of CPT 36416 when billed with an Evaluation and Management service for members ages 6 and under. Wisconsin allows reimbursement for CPT code 99000 & 99001.


Unbundling - Identifies Services That Have Been Unbundled

Example: Unbundling lab panels. If component lab codes are billed on a claim along with a more comprehensive lab panel code that more accurately represents the service performed, the software will bundle the component codes into the more comprehensive panel code. The software will also deny multiple claim lines and replace those lines with a single, more comprehensive panel code when the panel code is not already present on the claim.

Code Description Status

80053 Comprehensive Metabolic Panel Disallow
85025 Complete CBC, automated and automated & automated differential WBC count Disallow
84443 Thyroid Stimulating Hormone Disallow
80050 General Health Panel Allow

Explanation: 80053, 85025 and 84443 are included in the lab panel code 80050 and therefore are not separately reimbursable. Those claim lines containing the component codes are denied and only the comprehensive lab panel code is reimbursed.

* Fragmentation - Billing all incidental codes or itemizing the components of procedures separately when a more comprehensive code is available.

* Age/Gender - Submitting codes inappropriate for the Member’s age or gender because of the nature of the procedure.

* Bilateral Surgery – Identical Procedures Performed on Bilateral Anatomical Sites during Same Operative Session: Example: Michigan Complete Health may request medical records or other documentation to assist in the determination of medical necessity, appropriateness of the coding submitted, or review of the procedure billed.


Indications and Limitations

A service or procedure on the "national non-coverage list" may be non-covered based on a specific exclusion contained in the Medicare law; for example, acupuncture; it may be viewed as not yet proven safe and effective and, therefore, not medically reasonable and necessary; or it may be a procedure that is always considered cosmetic in nature and is denied on that basis. The precise basis for a national decision to noncover a procedure may be found in references cited in this policy.

A service or procedure on the "local" list is always denied on the basis that Riverbend GBA does not believe it is ever "medically reasonable and necessary". Our list of local medical review policy exclusions contains procedures that, for example, are:

experimental

not yet proven safe and effective

not yet approved by the FDA


Reasons for Denial

An advance notice of Medicare’s denial of payment must be provided to the patient when the provider does not want to accept financial responsibility for a service that is considered investigational/experimental, or is not approved by the FDA, or because there is a lack of scientific and clinical evidence to support the procedure’s safety and efficacy.

The service does not follow the guidelines of this policy.

The service is considered:

Investigational

Cosmetic

Routine screening

Dental

Program exclusion

Otherwise not covered

Never medically necessary



Commercial insurance Guidelines

In addition, Moda Health covers a limited list of additional tests when billed with a routine, preventive, or screening diagnosis code. These tests are not on the PPACA list of mandated preventive services and so are not eligible for the 100%, no-cost-share Affordable Care Act preventive benefit. The tests will be covered but are subject to the member’s usual costsharing and deductible requirements.

The following additional CPT codes will be covered as noted above with a routine/preventive/screening diagnosis:

* 80048 (Basic metabolic panel)

* 80050 (General health panel)

* 80051(Electrolyte panel)

* 80053 (Comprehensive metabolic panel)

* 80061 (Lipid panel)

* 81001 (Urinalysis, by dip stick or tablet reagent; automated, with microscopy)

* 82310 (Calcium; total)

* 83036 (Hemoglobin; glycosylated (A1C))

* 83655 (Lead)

* 84443 (Thyroid stimulating hormone (TSH))

* 85025 (Blood count; complete (CBC), automated)

* Chlamydia screening for males (87110, 87270, 87370, 87490, 87491, 87492, 87810)


CLIA update

CPT 80053  requied CLIA certificate.

CLIA regulations require a facility to be appropriately certified for each test they perform. Laboratory claims are edited at the CLIA certificate level in order to
ensure the Centers for Medicare & Medicaid Services (CMS) pay only for  laboratory tests categorized as waived complexity under CLIA by facilities with a CLIA certificate of waiver.

The chart below identifies the newly added waived tests and their effective dates. The Current Procedural Terminology (CPT) codes for these tests must have the
QW modifier to be recognized as a waived test.

80053QW January 16, 2008 Abaxis Piccolo Blood Chemistry Analyzer (Comprehensive Metabolic Reagent Disc){Whole Blood}

80053QW January 16, 2008 Abaxis Piccolo xpress Chemistry Analyzer (Comprehensive Metabolic Reagent Disc){Whole Blood}


Comprehensive Metabolic Panel, 80053 

There are 3 configurations for a Comprehensive Metabolic Panel, CPT code 80053: 1. A submission that includes 10 or more of the following laboratory Component Codes by the Same Individual Physician or Other Health Care Professional for the same patient on the same date of service is a reimbursable service as a Comprehensive Metabolic Panel,

CPT code 80053


1 .Must contain 10 or more of the following Component Codes for the same patient on the same date of service:

82040 Albumin; serum, plasma or whole blood
82247 Bilirubin; total
82310 Calcium; total
82374 Carbon dioxide (bicarbonate)
82435 Chloride; blood
82565 Creatinine; blood
82947 Glucose quantitative, blood (except reagent strip)
84075 Phosphatase, alkaline
84132 Potassium; serum, plasma or whole blood
84155 Protein, total, except by refractometry; serum, plasma or whole blood
84295 Sodium; serum, plasma or whole blood
84450 Transferase, aspartate amino (AST) (SGOT)
84460 Transferase, alanine amino (ALT) (SGPT)
84520 Urea Nitrogen (BUN)

2. A submission that includes a Basic Metabolic Panel (Calcium, total), CPT code 80048, and 2 or more of the following laboratory Component Codes by the Same Individual Physician or Other Health Care Professional for the same patient on the same date of service is a reimbursable service as a Comprehensive Metabolic Panel, CPT code 80053.



80053 Comprehensive Metabolic Panel

Includes the following panel:
80048 Basic Metabolic Panel (Calcium, total)
Plus 2 or more of the following Component Codes for the same patient on
the same date of service:
82040 Albumin; serum, plasma or whole blood
82247 Bilirubin; total
84075 Phosphatase, alkaline
84155 Protein, total
84450 Transferase, aspartate amino (AST) (SGOT)
84460 Transferase; alanine amino (ALT) (SGPT)


3. A submission that includes an Electrolyte Panel, CPT code 80051, and 6 or more of the following laboratory Component Codes by the Same Individual Physician or Other Health Care Professional for the same patient on the same date of service is a reimbursable service as a Comprehensive Metabolic Panel,

80053 Comprehensive Metabolic Panel

Includes the following panel:

80051 Electrolyte Panel
Plus 6 or more of the following Component Codes for the same patient on the same date of service:

82040 Albumin; serum, plasma or whole blood
82247 Bilirubin; total
82310 Calcium; total
82565 Creatinine; blood
82947 Glucose; quantitative, blood (except reagent strip)
84075 Phosphatase, alkaline
84155 Protein, total, except by refractometry; serum, plasma or whole blood
84450 Transferase, aspartate amino (AST) (SGOT)
84460 Transferase; alanine amino (ALT) (SGPT)
84520 Urea nitrogen (BUN)
When the Same Individual Physician or Other Health Care Professional reports CPT 80053 with CPT
80048 or CPT 80076 for the same patient on the same date of service, neither CPT 80048 nor CPT
80076 will be reimbursed separately.


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 (bilirubin, direct). Therefore, when performed with all of the components of CPT 80053, report CPT 82248 separately.


The Organ or Disease-Oriented Panels as defined in the CPT book are codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, and 80076. According to the CPT book, these panels were developed for coding purposes only and are not to be interpreted as clinical parameters.

UnitedHealthcare Community Plan uses CPT coding guidelines to define the components of each panel. UnitedHealthcare Community Plan also considers an individual component code included in the more comprehensive Panel Code when reported on the same date of service by the Same Individual Physician  or Other Health Care Professional. The Professional Edition of the CPT ® book, Organ or DiseaseOriented Panel section states: "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."

For reimbursement purposes, UnitedHealthcare Community Plan differs from the CPT book's inclusion of the specific number of Component Codes within an Organ or Disease-Oriented Panel. UnitedHealthcare Community Plan will deny the individual Component Codes and require the provider to submit the more comprehensive Panel Code. as set forth more fully in the tables below. The tables for CPT codes 80047, 80048, 80050, 80051, 80053, 80061, 80069, 80074 and 80076 identify the Component Codes that UnitedHealthcare Community Plan will require the submission of the specific panel.

CBS

CPT : 85004, 85007, 85008, 85013 , 85014, 85018, 85025, 85027, 85032, 85048, 85049


Coverage Indications, Limitations, and/or Medical Necessity


Blood counts are used to evaluate and diagnose diseases relating to abnormalities of the blood or bone marrow. These include primary disorders such as anemia, leukemia, polycythemia, thrombocytosis and thrombocytopenia. Many other conditions secondarily affect the blood or bone marrow, including reaction to inflammation and infections, coagulopathies, neoplasms and exposure to toxic substances. Many treatments and therapies affect the blood or bone marrow, and blood counts may be used to monitor treatment effects. The complete blood count (CBC) includes a hemogram and differential white blood count (WBC). The hemogram includes enumeration of red blood cells, white blood cells, and platelets, as well as the determination of hemoglobin, hematocrit, and indices. The symptoms of hematological disorders are often nonspecific, and are commonly encountered in patients who may or may not prove to have a disorder of the blood or bone marrow. Furthermore, many medical conditions that are not primarily due to abnormalities of blood or bone marrow may have hematological manifestations that result from the disease or its treatment. As a result, the CBC is one of the most commonly indicated laboratory tests.

In patients with possible hematological abnormalities, it may be necessary to determine the hemoglobin and hematocrit, to calculate the red cell indices, and to measure the concentration of white blood cells and platelets. These measurements are usually performed on a multichannel analyzer that measures all of the parameters on every sample. Therefore, laboratory assessments routinely include these measurements.

Indications


Indications for a CBC or hemogram include red cell, platelet, and white cell disorders. Examples of these indications are enumerated individually below.

1. Indications for a CBC generally include the evaluation of bone marrow dysfunction as a result of neoplasms, therapeutic agents, exposure to toxic substances, or pregnancy. The CBC is also useful in assessing peripheral destruction of blood cells, suspected bone marrow failure or bone marrow infiltrate, suspected myeloproliferative, myelodysplastic, or lymphoproliferative processes, and immune disorders.

2. Indications for hemogram or CBC related to red cell (RBC) parameters of the hemogram include signs, symptoms, test results, illness, or disease that can be associated with anemia or other red blood cell disorder (e.g., pallor, weakness, fatigue, weight loss, bleeding, acute injury associated with blood loss or suspected blood loss, abnormal menstrual bleeding, hematuria, hematemesis, hematochezia, positive fecal occult blood test, malnutrition, vitamin deficiency, malabsorption, neuropathy, known malignancy, presence of acute or chronic disease that may have associated anemia, coagulation or hemostatic disorders, postural dizziness, syncope, abdominal pain, change in bowel habits, chronic marrow hypoplasia or decreased RBC production, tachycardia, systolic heart murmur, congestive heart failure, dyspnea, angina, nailbed deformities, growth retardation, jaundice, hepatomegaly, splenomegaly, lymphadenopathy, ulcers on the lower extremities).

3. Indications for hemogram or CBC related to red cell (RBC) parameters of the hemogram include signs, symptoms, test results, illness, or disease that can be associated with polycythemia (for example, fever, chills, ruddy skin, conjunctival redness, cough, wheezing, cyanosis, clubbing of the fingers, orthopnea, heart murmur, headache, vague cognitive changes including memory changes, sleep apnea, weakness, pruritus, dizziness, excessive sweating, visual symptoms, weight loss, massive obesity, gastrointestinal bleeding, paresthesias, dyspnea, joint symptoms, epigastric distress, pain and erythema of the fingers or toes, venous or arterial thrombosis, thromboembolism, myocardial infarction, stroke, transient ischemic attacks, congenital heart disease, chronic obstructive pulmonary disease, increased erythropoietin production associated with neoplastic, renal or hepatic disorders, androgen or diuretic use, splenomegaly, hepatomegaly, diastolic hypertension.)

4. Specific indications for CBC with differential count related to the WBC include signs, symptoms, test results, illness, or disease associated with leukemia, infections or inflammatory processes, suspected bone marrow failure or bone marrow infiltrate, suspected myeloproliferative, myelodysplastic or lymphoproliferative disorder, use of drugs that may cause leukopenia, and immune disorders (e.g., fever, chills, sweats, shock, fatigue, malaise, tachycardia, tachypnea, heart murmur, seizures, alterations of consciousness, meningismus, pain such as headache, abdominal pain, arthralgia, odynophagia, or dysuria, redness or swelling of skin, soft tissue bone, or joint, ulcers of the skin or mucous membranes, gangrene, mucous membrane discharge, bleeding, thrombosis, respiratory failure, pulmonary infiltrate, jaundice, diarrhea, vomiting, hepatomegaly, splenomegaly, lymphadenopathy, opportunistic infection, such as oral candidiasis.)

5. Specific indications for CBC related to the platelet count include signs, symptoms, test results, illness, or disease associated with increased or decreased platelet production and destruction, or platelet dysfunction (e.g., gastrointestinal bleeding, genitourinary tract bleeding, bilateral epistaxis, thrombosis, ecchymosis, purpura, jaundice, petechiae, fever, heparin therapy, suspected DIC, shock, pre-eclampsia, neonate with maternal ITP, massive transfusion, recent platelet transfusion, cardiopulmonary bypass, hemolytic uremic syndrome, renal diseases, lymphadenopathy, hepatomegaly, splenomegaly, hypersplenism, neurologic abnormalities, viral or other infection, myeloproliferative, myelodysplastic, or lymphoproliferative disorder, thrombosis, exposure to toxic agents, excessive alcohol ingestion, autoimmune disorder (SLE, RA).

6. Indications for hemogram or CBC related to red cell (RBC) parameters of the hemogram include, in addition to those already listed, thalassemia, suspected hemoglobinopathy, lead poisoning, arsenic poisoning, and spherocytosis.

7. Specific indications for CBC with differential count related to the WBC include, in addition to those already listed, storage diseases; mucopolysaccharidoses, and use of drugs that cause leukocytosis such as G-CSF or CM-CSF.

8. Specific indications for CBC related to platelet count include, in addition to those already listed, May-Hegglin syndrome and Wiskott-Aldrich syndrome.

Limitations

1. Testing of patients who are asymptomatic, or who do not have a condition that could be expected to result in a hematological abnormality, is screening and is not a covered service.

2. In some circumstances it may be appropriate to perform only a hemoglobin or hematocrit to assess the oxygen carrying capacity  of the blood. When the ordering provider requests only a hemoglobin or hematocrit, the remaining components of the CBC are not covered.

3. When a blood count is performed for an end-stage renal disease (ESRD) patient, and is billed outside the ESRD rate, documentation of the medical necessity for the blood count must be submitted with the claim. 4. In some patients presenting with certain signs, symptoms or diseases, a single CBC may be appropriate. Repeat testing may not be indicated unless abnormal results are found, or unless there is a change in clinical condition. If repeat testing is performed, a more descriptive diagnosis code  (e.g., anemia) should be reported to support medical necessity. However, repeat testing may be indicated where results are normal in patients with conditions where there is a continued risk for the development of hematologic abnormality.

4. In some patients presenting with certain signs, symptoms or diseases, a single CBCmay be appropriate. Repeat testing may not be indicated unless abnormal results arefound, or unless there is a change in clinical condition. If repeat testing is performed, amore descriptive diagnosis code (e.g., anemia) should be reported to support medicalnecessity. However, repeat testing may be indicated where results are normal inpatients with conditions where there is a continued risk for the development ofhematologic abnormality.

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