ORGAN OR DISEASE ORIENTED PANELS
CODE DESCRIPTION
80048 Basic metabolic panel (Calcium, total) This panel must include the following: Calcium, total (82310), Carbon dioxide (82374), Chloride (82435), Creatinine (82565), Glucose (82947), Potassium (84132), Sodium (84295), Urea Nitrogen (BUN) (84520)
G0382 (Level 3 hospital ED visit provided in a type B ED)
Organ or Disease Oriented Panels (80048–80076) Report organ or disease–oriented panel codes only when each panel component in the panel definition is performed. The assignment of organ or disease oriented panel codes is optional for most non–Medicare payers. You may assign an organ or disease panel code or opt to report each individual assay code. Medicare guidelines states that if all tests of a CPT defined panel are performed, the provider may bill the panel code or the individual component test codes. The panel codes may be used when the tests are ordered as that panel or if the individual component tests of a panel are ordered separately.
For example, if the individually ordered tests are cholesterol (CPT code 82465), triglycerides (CPT code 84478), and HDL cholesterol (CPT code 83718), the service could be billed as a lipid panel (CPT code 80061)
80048 Basic metabolic panel
A basic metabolic panel includes the following tests: calcium (82310), carbon dioxide (82374), chloride (83435), creatinine (82565), glucose (82947), potassium (84132), sodium (84295), and urea nitrogen (BUN) (84520). Blood specimen is obtained by venipuncture. See the specific codes for additional information about the listed tests.
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.
Code 80053 can not be used in addition to CPT codes 80048 and 80076.
Requirement
Contractors shall be aware of the correction to the table in IOM Publication 100-04 – Claims Processing Manual, Chapter 16 – Laboratory Services, section 90.2 – Organ and Disease Oriented Panels. CPT 84075 (Alkaline phosphatase) was removed from under 80048 (Basic Metabolic Panel) to under 80053 (Comprehensive Metabolic Panel).
When procedures for Vitamin B12 (82607) and Folate (82746 or 82747) are performed in combination, the maximum reimbursable fee for code 82746 or 82747 is $6.25. When a procedure for Ferritin (82728) is performed in combination with Vitamin B12 or Folate, or any of the Organ or Disease Oriented Panels (80048-80076), or any of the individual chemistry analyte codes listed in the fee schedule (see Rule 6A), the maximum reimbursable fee for 82728 is $5.70.
Organ or Disease Orientated Panel codes. Effective July 1, 2000, the panel codes 80047, 80048, 80051, 80053, 80061, 80069 and 80076 should be used to bill designated combinations of tests regardless of whether the tests are ordered and/or performed individually, as a panel, or as multiple panels at different times. If 2 or more panel codes with overlapping component tests, (i.e., 80047, 80048, 80051, 80053, 80076) are billed, the lab is not entitled to reimbursement for the duplicate
tests. If one or more of the codes for chemistry tests where this rule applies are billed in combination with another and/or a panel code, total payment due for those chemistry tests is limited as follows: up to 2=$5.03, 3-6=$6.04, 7-9=$7.25, 10-12=$9.09, 13-16=$10.00, 17-18=$11.00, 19 or more=$12.00.
DESCRIPTION
Multiple Component Blood Tests
The first entry in the Pathology and Laboratory Section of the Current Procedural Terminology (CPT®’) manual is labeled “Organ or Disease Oriented Panels.” Under the code for each blood panel is an inclusive list of each component code which when grouped together comprise the entire blood panel. CPT indicates that these panels were developed for coding purposes only. The blood panels are:
Code Description
80048 Basic metabolic panel (calcium, total)
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.
? Downcoding a service in order to use an additional code when one higher level, more comprehensive code is appropriate:
• A laboratory should bill CPT code 80048, (basic metabolic panel), when coding for a calcium, carbon dioxide, chloride, creatinine, glucose, potassium, sodium, and urea nitrogen performed as automated multi channel tests.
• It would be inappropriate to report CPT codes 82310, 82374, 82435, 82565, 82947, 84132, 84295 and/or 84520 in addition to the CPT code 80048
CODING
NOTE: The Current Procedural Terminology (CPT®) codes and Healthcare Common Procedure Coding System (HCPCS) codes listed in this policy are for reference purposes only. Listing of a code in this policy does not imply that the service is covered and is not a guarantee of payment. Other policies and coverage guidelines may apply. When reporting services, providers/facilities should code to the highest level of specificity using the code that was in effect on the date the service was rendered. This list may not be all inclusive.
The following CPT codes are considered STAT labs.
Code Description
80048 BMP Ca total
Modifier – 91 Example 6
• Basic metabolic panel (80048) and electrolyte panel (80051)
• Physician orders a basic metabolic panel (80048).
After reviewing the results and treating the patient, he orders a follow-up electrolyte panel (80051)
• 80048
• 80051-91
Description
This policy is intended to provide guidance for Emergency Department (ED) Facilities who bill for services rendered using the CMS 1500 and/or UB04 forms. Appropriate coding should be submitted that correctly describesthe health care services rendered. The information in this policy serves only as a reference resource for the ED Services described and is not intended to be all inclusive. In addition, this policy applies to In-network and out of network facilities submitting ED claims
(Place of Service -23).
Claim submissions coded with the correct combination of procedure code(s) is critical to minimizing potential delays in claim(s) processing. Claim submissions must contain revenue codes that reflect the services rendered. A revenue code and corresponding HCPCS or CPT code must be compatible.
CMS Coding Principles- CMS has indicated coding principles applicable to emergency department services are to include coding guidelines that should be based on facility resources.
The Plan reserves the right to request supporting documentation. Claims that do not adhere to coding and billing guidelines may result in a denial or reassigned payment rate. Claims are reviewed on a case by case basis.
Reimbursement Information:
The member’s medical record documentation for diagnosis and treatment in the ED must indicate the presenting symptoms, diagnoses and treatment plan and a written order by the provider. All contents of medical records should be clearly documented. Medical records and itemized bills may be requested from the facility/provider for review to validate the level of care and services billed.
If observation services are billed with any of the ED associated Evaluation and Management (E/M) codes, industry standard guidelines, such as MCG Criteria, will be used to evaluate observation hours.
Facility Level of Care Guideline
The chart below is a guideline for appropriate facility ED billing for each defined Level of Care.
The CPT/HCPCS code (level of care) column corresponds to the “Possible Services Rendered” column. The appropriate facility level of care is determined by the services rendered. A review of services may be conducted in accordance with the member’s benefits using standard medical guidelines as outlined in the chart below. A facility level of care may encompass multiple “Possible Services Rendered” and may not be limited to one (1) service outlined in the chart below.
At least one (1) service under the “Possible Service Rendered” column must be documented in the member’s medical record to satisfy reimbursement requirements for the CPT or HCPCS billed for the facility level of care code. Emergency department service codes 99281-99285 describe E/M services provided in the ED and must include the history, exam and medical decision-making in the documentation.
CPT/HCPCS CODE POSSIBLE SERVICES RENDERED
G0382 (Level 3 hospital ED visit provided in a type B ED) • One nebulizer treatment
• Preparation for lab tests described in CPT (80048-87999 codes)
• Preparation for plain X-rays of 1 or 2 more body areas (not above/below joint of same limb)
• Prescription medications non-parenteral
• Foley catheters placement; In & out catherization
• C-spine precautions – cervical stabilization device present
• Corneal exam with dye
• Epistaxis with packing
• Oxygen therapy
• Emesis/Incontinence care
• Prep or assist with procedures such as joint aspiration/injection, simple fracture care,
intermediate/complex laceration repair, etc.
• Mental health anxiety with simple treatment
• Routine psych medical clearance
• Post mortem care
• Direct admit via ED
• Discharged w/prescription medication
General Background
The National Correct Coding Initiative (NCCI) was developed by the Centers for Medicare and Medicaid Services (CMS) to promote national correct coding methodologies and to control improper coding leading to inappropriate reimbursement. Cigna recognizes the appropriateness of many NCCI edits and considers the logic behind the edits to be applicable to facility claims.
The purpose of the NCCI edits is to prevent improper payment when incorrect code combinations are reported. The NCCI contains two tables of edits. The Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits table include code pairs that should not be reported together.
Correct Coding Initiative (CCI) edits are pairs of CPT or Healthcare Common Procedure Coding System (HCPCS) Level II codes that are not separately payable except under certain circumstances. The edits are applied to services billed by the same provider for the same beneficiary on the same date of service. Correct coding practice should be followed when billing for laboratory tests and services. For example, procedures should be reported with the most comprehensive CPT code that describes the services performed. Unbundling the services described by a HCPCS/CPT codes is not permitted.
According to the CPT Manual if a laboratory performs all tests included in one of these panels, the laboratory must report the CPT code for the organ or disease-oriented panel, not the CPT codes for the individual tests. The individual tests that make up a panel are not to be separately reported.
Example: CPT code 80061 (Lipid panel) includes the following tests:
82465 Cholesterol, serum or whole blood, total
83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
84478 Triglycerides
When all three tests are performed on the same date of service, the panel test, CPT code 80061 should be reported in place of the individual tests.
NCCI edits pair each panel CPT code with each CPT code for the individual laboratory tests that are included in the panel. These edits allow use of NCCI-associated modifiers to over-ride them if one or more of the individual laboratory tests are repeated on the same date of service. 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. If additional related procedures are necessary to provide or verify the result of a test previously performed, these would be considered part of the initial ordered test. For example, if a patient has an abnormal test result and repeat performance of the test is done to verify the result, the test is reported as one unit of service rather than two.
Coding/Billing Information
Note: 1) This list of codes may not be all-inclusive.
2) Deleted codes and codes which are not effective at the time the service is rendered may not be eligible for reimbursement.
Reimbursement will be provided for panel tests when all of the individual tests performed are included in the panel and when the code for the panel is reported:
CPT®* Codes Description
80048 Basic metabolic panel (Calcium, total). This panel must include the following: Calcium, total (82310) Carbon dioxide (82374) Chloride (82435) Creatinine (82565) Glucose (82947) Potassium (84132) Sodium (84295) Urea nitrogen (BUN) (84520)
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