Billing Lipid Panel Services eCBR

This electronic Comparative Billing Report (eCBR) focuses on providers that bill for CPT® codes 80061 and 83721 Services. 

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This eCBR information is one of the many tools used by Palmetto GBA to assist individual providers in identifying variation and improving performance. Becoming proactive in addressing potential billing issues and performing internal audits will help ensure you are in compliance with Medicare guidelines.

Overview of Billing for CPT® Codes 80061 and 83721 Services

The Centers for Medicare & Medicaid Services (CMS) has established national guidelines related to lipid panels in National Coverage Determination (NCD) 190.23. Any one component of the panel or a measured LDL may be reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy.

More frequent total cholesterol, HDL cholesterol, 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. LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.

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. The most important step you can take is to check the NCD guidelines before you submit a claim.

Documentation must comply with all legal/regulatory requirements applicable to Medicare claims. CMS outlines its minimal documentation requirement in the Medicare Benefit Policy Manual Publication, 100-02, Chapter 15, Section 220.3 (PDF).

CMS works to eliminate improper payments in the Medicare Program and protect the Medicare Trust Fund, as well as beneficiaries from medically unnecessary services or supplies and their associated costs. CMS calculates a national Medicare Fee-for-Service (FFS) improper payment rate and improper payment rates by claim type and publishes the review results annually.

Methods

The metrics reviewed in this eCBR are the proportion of billing for claims for CPT® codes 80061 and 83721 services on the same day. The report includes billed claims for comparisons performed to peers within the state and jurisdiction. This report is an analysis of Medicare Part B claims extracted from the Palmetto GBA data warehouse. The analysis shows the portions of your billing at each level compared to your peers in Jurisdictions J/M.

Example of eCBR

Resources

• NCD-Lipid Testing (190.23)
• Lipid Panels: Medical Necessity Denials
  • Jurisdication J Part B 
  • Jurisdiction M Part B