Sunday, June 19, 2011

- CPT codes: 36415, 80048, 80053, 80061, 83036, 84443, 85610 - CPT modifier 91 - To avoid duplicate denial

Clinical Laboratory Procedures: Duplicate Denials - CO18

Denial Reason, Reason/Remark Code(s)

CO-18 - Duplicate Service(s): Same service submitted for the same patient

• CPT codes: 36415, 80048, 80053, 80061, 83036, 84443, 85610

Resolution/Resources

First: Verify the status of your claim before resubmitting. Use the Online Provider Services (OPS) tool or call the Interactive Voice Response unit (IVR).

• All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.

• Access the introductory article to learn more: click on the 'Introducing Online Provider Services' graphic on the top of any of our main state Web pages

• One important consideration: only one Provider Administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The Provider Administrator can then grant permission to additional users related to that PTAN/NPI.

• Billing services and clearinghouses should contact their provider clients to gain access to the system

• Specific instructions for accessing claim status information through OPS are available in the OPS User Manual

CPT modifier 91 may be submitted to identify an identical laboratory test for the same patient on the same date.

• This modifier may not be submitted when tests are rerun to confirm initial results due to testing problems with specimens or equipment, or for any other reason when a normal, one-time, reportable result is all that is required

• This modifier may not be used when other codes describe a series of test results (e.g., glucose tolerance tests)

• For clinical laboratory tests ordered by an ESRD facility: these tests must be submitted with CPT modifier 91 if any single service (same CPT code) is ordered for the same patient, and the specimen is collected more than once in a single day, and the service is medically necessary

o CPT modifier 91 must be submitted with services that meet these criteria, regardless of whether the test is also submitted with HCPCS modifiers CD, CE or EF

o Any line item on a claim that meets these criteria and is submitted with CPT modifier 91 will be included into the calculation of the 50/50 rule

o After calculation of the 50/50 rule, services used to determine the payment amount may not exceed 22



Laboratory Panels

Individual laboratory codes, which together make up a laboratory Panel Code, will be denied. The provider will be required to submit the more comprehensive laboratory Panel Code as described under the specific laboratory panel headings below. Organ or Disease-Oriented Laboratory Panel Codes

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.

Basic Metabolic Panel (Calcium, total), 80048

CPT coding guidelines indicate that a Basic Metabolic Panel (Calcium, total), CPT code 80048 should not be reported in conjunction with 80053. If a submission includes CPT 80048 and CPT 80053, only CPT 80053 will be reimbursed. There are 2 configurations for a Basic Metabolic Panel (Calcium, total), CPT code 80048:

1. A submission that includes 5 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 Basic Metabolic Panel (Calcium, total), CPT code 80048.

Panel Code Component Code Code Description

80048 Basic Metabolic Panel (Calcium, total), 80048 Must contain 5 or more of the following Component Codes for the same patient on the same date of service

82310 Calcium; total
82374 Carbon Dioxide (bicarbonate)
82435 Chloride; blood
82565 Creatinine; blood
82947 Glucose; quantitative, blood (except reagent strip)
84132 Potassium; serum, plasma or whole blood
84295 Sodium; serum, plasma or whole blood
84520 Urea nitrogen (BUN)

2. A submission that includes an Electrolyte Panel, CPT code 80051 plus 1 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 Basic Metabolic Panel (Calcium, total) CPT code 80048.

Panel Code Component Code Code Description

80048 Basic Metabolic Panel (Calcium, total), 80048

Includes the following panel: 80051 Electrolyte Panel.

Plus 1 or more of the following Component Codes for the same patient on the same date of service:
82310 Calcium; total
82565 Creatinine; blood
82947 Glucose; quantitative, blood (except reagent strip)

84520 Urea nitrogen (BUN)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.

Panel Code Component Code Code Description

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, CPT code 80053.

Panel Code Component

Code Code Description 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. Obstetric Panel, 80055

A submission that includes one of the following CBC or combination of CBC Component Codes, either CPT codes 85025 or 85027 + 85004 or CPT codes 85027 + 85007 or 85027 + 85009 and each component CPT code Syphilis, non-treponemal antibody 86592, Antibody, Rubella, 86762, RBC antibody screen, 86850, Blood typing ABO, 86900, Blood typing RH (D), 86901 and Hepatitis B surface antigen (HBsAg), 87340 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 an Obstetric Panel, CPT code 80055.

NOTE: The Hepatitis B Surface Antigen (87340) is a component code of both the Obstetric Panel (80055) and the Acute Hepatitis Panel (80074). The Obstetric Panel takes Precedence.

NOTE: Renal Function Panel, 80069, includes the Basic Metabolic Panel, CPT code 80048, submitted by the Same Individual Physician or Other Health Care Professional for the same patient on the same date of service.

Panel Code Component Code Code Description 80069 Renal Function Panel 

Includes 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
82310 Calcium; total
82374 Carbon dioxide (bicarbonate)
82435 Chloride; blood
82565 Creatinine; blood
82947 Glucose; quantitative, blood (except reagent strip)
84100 Phosphorus inorganic (phosphate)
84132 Potassium; serum, plasma or whole blood
84295 Sodium; serum, plasma or whole blood
84520 Urea nitrogen (BUN)

Acute Hepatitis Panel, 80074

A submission that includes all 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 an Acute Hepatitis Panel, CPT code 80074.

NOTE: Hepatitis B Surface Antigen (87340) is a Component Code for both the Obstetric Panel, CPT code 80055, and the Acute Hepatitis Panel, CPT code 80074. The Obstetric Panel, CPT code 80055, takes Precedence.

Panel Code Component Code Code Description

80074 Acute Hepatitis Panel

Includes all of the following Component Codes for the same patient on the same date of service:
86705 Hepatitis B core antibody IgM (HBcAb)
86709 Hepatitis A antibody (HAAb), IgM
86803 Hepatitis C antibody
87340 Hepatitis B surface antigen (HBsAg) 

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