Guidelines for Coding Cholesterol And Lipid Panels, Part 1
Guidelines for Coding Cholesterol And Lipid Panels, Part 1
(Editor’s note: This is part one of a two-part article on cholesterol and lipid panels. Part two, in our March 26, 2001, issue, will discuss the coding guidelines and how to review claims denials.)
Once again, the Department of Health and Human Services Office of Inspector General (OIG) has turned its attention to coding for laboratory services. One of the goals listed in its fiscal year (FY) 2001 Work Plan is to “determine whether cholesterol tests billed to Medicare are medically necessary and accurately coded.” According to the OIG, Medicare claims reflect a preponderance of claims for lipid panels, which in addition to cholesterol, also include HDL cholesterol and triglyceride levels.
Although it is too soon to determine how extensive any OIG investigations related to lipid testing may be, the information below provides a starting point to help determine potential compliance risks.
Target CPT Codes
Lipoproteins are a class of heterogeneous particles of varying sizes and densities containing lipid and protein. They include cholesterol esters and free cholesterol; triglycerides; phospholipids; and A, C and E apoproteins.
Total cholesterol refers to all of the cholesterol found in various lipoproteins. In many individuals, an elevated blood cholesterol level constitutes an increased risk of developing coronary artery disease. Blood levels of total cholesterol and various fractions of cholesterol (especially low-density lipoprotein cholesterol [LDL-C] and high-density lipoprotein cholesterol [HDL-C]) are used to assess and monitor treatment for high-risk patients.
The codes listed below may be of interest to the OIG.
80061 Lipid panel
82465 Cholesterol, serum, total
83715 Lipoprotein, blood; electrophoretic separation and quantitation
83716 High-resolution fractionation and quantitation of lipoprotein cholesterols (for example, electrophoretic, nuclear magnetic resonance, ultracentrifugation)
83718 Lipoprotein, direct measurement; high-density cholesterol (HDL cholesterol)
83721 LDL cholesterol
Review Clinical Indications
The medical community recognizes lipid testing as appropriate for evaluating atherosclerotic cardiovascular (CV) disease. The following conditions also may be indicated when medical staff order lipid tests.
- Primary dyslipidemias
- Atherosclerotic disease
- Diseases associated with altered lipid metabolism, such as nephrotic syndrome, pancreatitis, hepatic disease and hypo- and hyperthyroidism
- Secondary dyslipidemias, including diabetes mellitus, disorders of gastrointestinal absorption, chronic renal failure and signs or symptoms of dyslipidemias such as skin lesions
Lipid testing also may be indicated as a follow-up to the initial screen for coronary heart disease (total cholesterol + HDL cholesterol) when total cholesterol is determined to be high (>240 mg/dL), or borderline (200-240 mg/dL), and the patient has two or more coronary heart disease risk factors or an HDL cholesterol <35 mg/dL.
To monitor the progress of patients on anti-lipid dietary management and pharmacologic therapy for the treatment of elevated blood lipid disorders, the following tests may be used: total cholesterol, HDL cholesterol and LDL cholesterol. Triglycerides may be obtained if this lipid fraction is also elevated or if the patient has been put on certain drugs that may raise the triglyceride level (e.g., thiazide diuretics, beta blockers, estrogens, glucocorticoids and tamoxifen).
When monitoring long-term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, performing the lipid panel annually (80061) will usually be adequate. Measurement of the serum total cholesterol (82465) or a measured LDL (83721) should suffice for interim visits, if the patient does not have hypertriglyceridemia (e.g., ICD-9-CM code 272.1, pure hyperglyceridemia).
Any one component of the panel or a measured LDL may be considered reasonable and necessary up to six times the first year for monitoring dietary or pharmacologic therapy. For marked elevations, more frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated. It also may be appropriate 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.
Electrophoretic or other quantitation of lipoproteins (83715 and 83716) may be indicated if the patient has a primary disorder of lipoid metabolism (ICD-9-CM codes 272.0 to 272.9).
Lipid panel and hepatic panel testing may be used for patients with severe psoriasis that has not responded to conventional therapy and for which retinoid estretinate has been prescribed and who have developed hyperlipidemia or hepatic toxicity. Specific examples include erythrodermia and generalized pustular-type psoriasis associated with arthritis.
Once a diagnosis is established, one or several specific tests are usually adequate for monitoring. Less specific diagnoses (e.g., other chest pain) alone do not support medical necessity.
Generally, a lipid panel would not be indicated more than twice per year when evaluating non-specific chronic abnormalities of the liver (e.g., elevations of transaminase, alkaline phosphatase, abnormal imaging studies). If no dietary or pharmacological therapy is advised, monitoring is not necessary.
Medicare does not cover routine screening and prophylactic testing for lipid disorders even though they may be medically appropriate. Lipid testing in asymptomatic individuals is considered to be screening regardless of the presence of other risk factors.
Randy Wiitala is senior health care consultant, Medical Learning Inc., St. Paul, MN.