Q&A: Billing repeat laboratory tests
Q: A patient has multiple labs on the same date of service:
- CPT code 80053 (comprehensive metabolic panel) at 0339
- 80048 (basic metabolic panel) at 1014
- 80048 at 2015
We receive the following NCCI edit: “Code 80048 is a column two code of 80053. These codes cannot be billed together in any circumstances.”
Should we only bill code 80053?
A: No, as long as the tests were for distinct clinical information (test 1 was likely a complete baseline, tests 2 and 3 were to see if treatment is working, the patient is progressing, etc.). Just make sure the record isn’t indicating that the results from the prior tests were slow and that is the reason for the later tests. In other words, as long as each test is performed at distinct times and to test for new information on the patient’s condition, you should be able to use modifier -91 (repeat clinical diagnostic laboratory test).
According to the Medicare Claims Processing Manual, Chapter 16, sections 90.2 and 90.3, since the A/B MACs are advised to deny duplicates, a modifier must be used on the individual duplicate components in order to justify medical necessity.
Per the 2016 NCCI Manual, Chapter X, Section C, p. 5, the subsequent panels should be unbundled and the individual medically necessary components reported with modifier -91:
NCCI contains edits pairing each panel CPT code (column one code) with each CPT code corresponding to the individual laboratory tests that are included in the panel (column two code). These edits allow use of NCCI-associated modifiers to bypass them if one or more of the individual laboratory tests are repeated on the same date of service. The repeat testing must be medically reasonable and necessary. Modifier -91 may be utilized to report this repeat testing. Based on the Internet-only Manuals (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 16, Section 100.5.1, the repeat testing cannot be performed to “confirm initial results; due to testing problems with specimens and equipment or for any other reason when a normal, one-time, reportable result is all that is required.”
Editor’s note: Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, president/CEO and principal consultant for SLG, Inc., of Raleigh, North Carolina, and Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, CPAR, CPC, COC, executive vice president of Healthcare Consulting Services at Med Law Advisors in Atlanta, answered this question.
Need expert advice? Email your questions for consideration in the Revenue Cycle Daily Advisor. Note: We do not guarantee that all questions will be answered.