Medicare coding and reimbursement for clinical laboratory services

¹ Because total and direct bilirubin are coded using the same CPT code (82251), HCFA has chosen to count the CPT codes rather than the number of tests and pay this six-test panel as though it contained only five tests. The old Hepatic Function Panel (80058) included bilirubin (total or direct), which when coded separately is 82250. The new Hepatic Function Panel includes bilirubin (total and direct), which when coded separately is 82251.

Medicare will continue to increase its efforts to cut spending through aggressive review of claims and the use of new fraud and abuse regulations. Providers must be especially careful to provide correct procedure codes that define precisely what services have been provided and accurate diagnosis codes that link those procedures or tests to an appropriate diagnosis. Medicare reimbursement rules for clinical laboratory procedures are explained, including the proper use of procedure and diagnosis codes. Coding and payment for new automated test panels are discussed, as well as the economic consequences of using smaller panels. Medicare coverage requirements, including medical necessity, are described, as well as the proper use of advance beneficiary notices and the Medicare appeals process.

The following articles in journals at HighWire Press have cited this article:

				Y. Takemura, H. Ishida, Y. Inoue, and J. R. Beck Yield and Cost of Individual Common Diagnostic Tests in New Primary Care Outpatients in Japan Clin. Chem., January 1, 2002; 48(1): 42 - 54. [Abstract] [Full Text] [PDF]

				Y. Takemura, H. Ishida, Y. Inoue, H. Kobayashi, and J. R. Beck Opportunistic Discovery of Occult Disease by Use of Test Panels in New, Symptomatic Primary Care Outpatients: Yield and Cost of Case Finding Clin. Chem., August 1, 2000; 46(8): 1091 - 1098. [Abstract] [Full Text] [PDF]

				Y. Takemura, H. Ishida, Y. Inoue, and J. R. Beck Common Diagnostic Test Panels for Clinical Evaluation of New Primary Care Outpatients in Japan: A Cost-Effectiveness Evaluation Clin. Chem., October 1, 1999; 45(10): 1752 - 1761. [Abstract] [Full Text] [PDF]

				D. Baorto and M. Scott The Value of Screening Inpatients with Creatine Kinase Testing Clin. Chem., March 1, 1999; 45(3): 424 - 426. [Full Text] [PDF]