CODE DESCRIPTION
80053 Comprehensive metabolic panel This panel must include the following: Albumin (82040), Bilirubin, total (82247), Calcium, total (82310), Carbon dioxide
(bicarbonate) (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Phosphatase, alkaline (84075), Potassium (84132), Protein, total (84155), Sodium (84295), Transferase, alanine amino (ALT) (SGPT) (84460), Transferase, aspartate amino (AST) (SGOT) (84450), Urea Nitrogen (BUN) (84520)
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, 80076, and 80081. According to the CPT book, these panels were developed for coding purposes only and are not to be interpreted as clinical parameters. UnitedHealthcare uses CPT coding guidelines to define the components of each panel.
UnitedHealthcare 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 Qualified Health Care Professional. The Professional Edition of the CPT ® book, Organ or Disease-Oriented 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 differs from the CPT book's inclusion of the specific number of Component Codes within an Organ or Disease-Oriented Panel. UnitedHealthcare will bundle the individual Component Codes into the more comprehensive Panel Code when the combined reimbursement for the individual Panel Code(s) exceeds the reimbursement amount of the Panel Code or when the designated number of Component Codes identified within a Panel Code are submitted as set forth more fully in the tables below. The tables for CPT codes 80047, 80048, 80050, 80051, 80053, 80055, 80061, 80069, 80074, 80076 and 80081 identify the Component Codes that UnitedHealthcare will rebundle into the specific panel.
CPT coding guidelines indicate that Panel CPT code 80047 should not be reported in conjunction with CPT code 80053. If a submission includes CPT 80047 and CPT 80053, only CPT 80053 will be reimbursed.
CPT coding guidelines indicate that, Panel CPT code 80048 should not be reported in conjunction with Panel CPT 80053. If a submission includes Panel CPT 80048 and 80053, only Panel CPT 80053 will be reimbursed. There are 2 configurations for, Panel CPT code 80048:
1. A submission that includes 5 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80048.
Panel Code: 80048
Must contain 5 or more of the following Component Codes for the same patient on the same date of service
82310 82374 82435 82565 82947
84132 84295 84520
A submission that includes, Panel CPT code 80053, Panel CPT code 84443 and one of the following Component Codes, either CPT codes 85025 or 85027 + 85004 or 85027 + 85007 or 85027 + 85009 by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service, Panel CPT code 80050.
Panel Code: 80050
Includes the following Panel Code: 80053
Plus the following Component Code: 84443
Plus 1 of the following CBC or combination of CBC Component Codes for the same patient on the same date of service: :
85025 85027 + 85027 + 85027 +
85004 85007 85009
When Panel CPT code 80076 is submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional for the same patient as Panel CPT codes 80050, and 80076 will not be separately reimbursed.
When Panel CPT code 80076 is submitted on the same date of service by the Same Individual Physician or Other Qualified Health Care Professional for the same patient as Panel CPT codes 80050, and 80076 will not be separately reimbursed.
Panel code 80053, a component of Panel code 80050, includes all components of Panel CPT code 80076 except for code 82248.
Panel, 80053
There are 3 configurations for Panel CPT code 80053:
1. A submission that includes 10 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80053.
Panel Code: 80053
Must contain 10 or more of the following Component Codes for the same patient on the same date of service:
82040 82247 82310 82374 82435
82565 82947 84075 84132 84155
84295 84450 84460 84520
2. A submission that includes a Panel CPT code 80048, and 2 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as, Panel CPT code 80053.
Panel Code: 80053
Includes the following Panel Code: 80048 Plus 2 or more of the following Component Codes for the same patient on the same date of service:
82040 82247 84075 84155 84450
84460
3. A submission that includes, Panel CPT code 80051, and 6 or more of the following laboratory Component Codes by the Same Individual Physician or Other Qualified Health Care Professional for the same patient on the same date of service is a reimbursable service as Panel CPT code 80053.
Panel Code: 80053
Includes the following Panel Code: 80051 Plus 6 or more of the following Component Codes for the same patient on the same date of service:
82040 82247 82310 82565 82947
84075 84155 84450 84460 84520
When the Same Individual Physician or Other Qualified Health Care Professional reports the Panel CPT codes 80053 with 80048 or 80076 for the same patient on the same date of service, neither Panel CPT codes 80048 nor 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. Therefore, when performed with all of the components of Panel CPT code 80053, report CPT 82248 separately.
Coding Tip
This panel must include the following: Calcium (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520). Code 80048 cannot be reported in conjunction with 80053.
80053 Comprehensive metabolic panel A comprehensive metabolic panel includes the following tests: albumin (82040), total bilirubin (82247), calcium (82310), carbon dioxide (bicarbonate) (82374), chloride (83435), creatinine (82565), glucose (82947), alkaline phosphatase (84075), potassium (84132), total protein (84155),
sodium (84295), alanine amino transferase (ALT) (SGPT) (84460), aspartate amino transferase (AST) (SGOT) (84450), and urea nitrogen (BUN) (84520). Blood specimen is obtained by venipuncture. See the specific codes for additional information about the listed tests
Code 80053 can not be used in addition to CPT codes 80048 and 80076.
This test may be performed using a CLIA-waived test system. Laboratories with a CLIA-waived certificate must report this code with modifier QW CLIA waived
test. See appendix 1 for CLIA-waived kits and test systems. Medicare covers colorectal screening for
* Indicates a mutually exclusive edit
80053 80048, 80051, 80069, 80076, 82040, 82247, 82310, 82374, 82435, 82565, 82947, 84075, 84132, 84155, 84295, 84450, 84460, 84520
Reimbursement is provided for tests that are performed in a panel if they are reasonable, medically necessary under the applicable medical policy, and otherwise reimbursable under the terms of the member's plan. The plan reserves the right to rebundle individual codes that belong to a panel. If a claim is submitted with individual codes that belong to a panel, our claim reviewers and/or correct coding software logic may rebundle the procedure codes for appropriate reimbursement. If the medical documentation submitted with a claim shows that a panel was ordered and performed but the claim submitted shows the individual components of the panel, claim reviewers may rebundle the codes into the appropriate panel for reimbursement. CPT states the following:
• Tests performed in addition to those specifically indicated for a particular panel should be reported separately from the panel code
Example, If the Electrolyte panel (80051) is billed, individual tests such as 82947 (Assay Glucose Blood Quant), 84520 (Assay of Urea Nitrogen), 82565 (Assay of
Creatinine) and 82550 (Assay of CK (CPK)) should be billed separately from the panel.
• Do not report two or more panel codes that include the same constituent tests performed from the same patient collection
Example, If the Comprehensive Metabolic Panel (80053) is billed, the Basic Metabolic Panel (80047) cannot be billed.
• If a group of tests overlaps two or more panels, you must use the panel that incorporates the greatest number of tests and report the remaining individual tests
Example, if 82374 (Assay of Blood Carbon Dioxide), 82435 (Assay of Blood Chloride), 84132 (Assay of Serum Potassium), 84295 (Assay of Serum Sodium), 84520 (Assay of
Urea Nitrogen), and 82947 (Assay Glucose Blood Quant) are billed, two panel codes overlap. The Basic Metabolic Panel (80047) and the Electrolyte Panel (80051) include
codes 82374 (Assay of Blood Carbon Dioxide), 82435 (Assay of Blood Chloride), 84132 (Assay of Serum Potassium) and 84295 (Assay of Serum Sodium). The Electrolyte Panel should be billed.
• The panel code should be billed when all individual tests in the panel have been performed and should not be billed separately
Example, If the Lipid Panel (80061) is billed, then procedures 82465 (Assay BLD/Serum Cholesterol), 83718 (Assay of Lipoprotein) and 84478 (Assay of Triglycerides) should have been performed.
80053 Comprehensive Metabolic Panel
82040 Assay of Serum Albumin
82247 Bilirubin Total
82310 Assay of Calcium
82374 Assay Blood Carbon Dioxide
82435 Assay of Blood Chloride
82565 Assay of Creatinine
82947 Assay Glucose Blood Quant
84075 Assay Alkaline Phosphatase
84132 Assay of Serum Potassium
84155 Assay of Protein Serum
84295 Assay of Serum Sodium
84460 Alanine Amino (ALT) (SGPT)
84450 Transferase (AST) (SGOT)
84520 Assay of Urea Nitrogen
Purpose of Policy
This policy is intended to help clarify how and why the same test or service may process differently depending upon the primary diagnosis code with which it is billed. The focus of this policy is on the differences between the Preventive and the Medical benefit categories.
Scope
This policy applies to all Commercial medical plans.
Reimbursement Guidelines
A. Categories of diagnostic tests covered and not covered as routine/preventive
1. Moda Health covers the preventive services mandated in the Patient Protection and Affordable Care Act (PPACA) at 100% (no cost-sharing responsibility to the member), when the member is seeing an in-network provider.
2. In addition to the mandated PPACA preventive services, Moda Health also covers a limited list of additional tests when billed with a routine, preventive, or screening diagnosis code.
The codes and tests eligible for this additional screening coverage are determined by a Moda Health Medical Director and are listed below. NOTE: These tests are not eligible for the 100%, no-cost-share Affordable Care Act preventive benefit because they are not on the PPACA list of mandated preventive services.
The tests will be covered (rather than denied), but all of the following tests are subject to the member’s usual cost-sharing and deductible requirements, even
when billed with a preventive diagnosis.
Lab Panels
Organ- or disease-oriented lab panels were developed to allow for coding of a group of tests. Providers are expected to bill the lab panel when all the tests listed within each panel are performed on the same date of service. When one or more of the tests within the panel are not performed on the same date of service,
providers may bill each test individually. Providers may not bill for a panel and all the individual tests listed within that panel on the same day. However, other tests performed in addition to those listed on the panel on the same date of service may be reported separately, in addition to the panel code. Providers must
follow CPT coding guidelines when reporting multiple panels. For example, providers cannot report basic panel code 80048 with comprehensive panel code 80053 on the same date of service, because all the lab tests in 80048 are components of 80053.
On May 3, 2019 CMS issued Change Request 11248, which re-implements the Automated Multi-Channel Chemistry (AMCC) Lab Panel Claims Payment System Logic. This logic was introduced in 2017 but was suspended beginning CY 2018, due to the Protecting Access to Medicare Act of 2014 (PAMA). PAMA required significant changes to how Medicare pays for Clinical Diagnostic Laboratory Tests (CDLTs) under the Clinical Laboratory Fee Schedule (CLFS). Under PAMA, reporting entities must report to CMS certain private payer rate information for their component applicable laboratories. The implementation of PAMA required Medicare to pay the weighted median of private payor rates for each separate HCPCS code, as one National fee schedule rate rather than individual rates per state.
Prior to PAMA, CMS paid for certain chemistry tests using Automated Test Panels (ATPs). ATPs used claims processing logic to apply a bundled rate to sets of these codes based off how many ATPs were ordered. The claims processing system would not pay more for all ATPs than the associated CPT Panel (80047-80081). Any duplicated chemistry tests across ATPs or separately billed without a 91 modifier are not counted in the ATP test total. Below will further illustrate the logic and the effect on reimbursement. The Ohio rate of the 2017 CLFS is used for this demonstration, as the 2019 CLFS has not been updated with ATP entries as of the time of this article.
Example
A lab receives an order for a Comprehensive Metabolic Panel (80053) and a Lipid Panel (80061). Both panels are processed, results sent to the referring provider and a claim is sent to Medicare for HCPCS 80053 and 80061. The 2017 CLFS indicates payment for each HCPCS code as:
80053 $14.49
80061 $17.45
Total $31.94
Under the ATP payment methodology, payment will be determined based off the total number of unique chemistry tests performed.
Medicare will first strip each panel into its component codes as follows:
80053 HCPCS 80061 HCPCS
82040 82465
82247 83718
82310 84478
82374
82435
82565
82947
84075
84132
84155
84295
84460
84450
84520
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