Fact Pattern: A patient’s Primary Care Provider or Admitting Physician has ordered a general health panel blood test to assess the baseline health of their patient. The lab analyst performs its clinical laboratory procedures and sends its records over to the billing department. As a standard test, your billing department instinctually enters CPT code 80050 into its UB-04 form and sends the claim for payment. Your business office receives an Electronic Remittance Advice from the payor and CPT code 80050 has been denied as an uncovered service. What went wrong?
Explanation: CPT code 80050 is a bundled code that encompasses a metabolic panel, a complete blood count, and a TSH level. Several different combinations of CPT codes can combine into CPT code 80050, those most common of which are CPT code 80053 (comprehensive metabolic panel), CPT code 85025 (complete blood count with differential), and CPT code 84443 (thyroid stimulating hormone test).
While the bundled CPT code 80050 is accepted by most commercial payors, as of Calendar Year 2018, the bundled CPT code 80050 is not payable under Medicare. However, state Medicaid agencies and several Medicare Advantage programs were slow to update their internal claims processing procedures, which allowed Providers to continued to be paid utilizing CPT code 80050 over the years.
Recently, however, state Medicaid agencies and Medicare Advantage programs have begun to enforce the CMS mandates and are retroactively terminating coverage for CPT code 80050. As a result, providers and facilities are receiving notices of recoupment and outright denials due to their use of CPT code 80050 in bills to these payors.
Solution: As a general rule, it is always best to confirm the responsible party’s billing guidelines and procedures prior to submitting your claim for service. If the payor is a government entity or a Medicare Advantage agency, the best practice is to bill for the individual components of CPT code 80050, such as CPT codes 80053, 85025, 84443, etc. This method will provide your billing department with ease of mind that its claim will be paid promptly.
For more information on how Abril Law can assist you in recognizing problematic billing issues, contact us today at (305) 373-0901.
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