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Professional Services -

Pathology and Laboratory Services

PANEL TESTS

Automated Multichannel Tests

When billing for panels containing automated multichannel tests, performing providers may bill either the panel code or individual test codes, but not both.

The following tests are automated multichannel tests or panels comprised solely of automated multichannel tests:

CPT® codes
80048	80069	82247	82374	82550	82977	84100	84295	84478
80051	80076	82248	82435	82565	83615	84132	84450	84520
80053	82040	82310	82465	82947	84075	84155	84460	84550

Calculating Payment for Automated Tests

The automated individual and panel tests above are paid based on the total number of unduplicated automated multichannel tests performed per day per patient. Calculate the payment according to the following steps:

When a panel is performed, the CPT® codes for each test within the panel are determined;

The CPT® codes for each test in the panel are compared to any individual tests billed separately for that day;

Any duplicated tests are denied;

The total number of remaining unduplicated automated tests is counted.

See the following table to determine the payable fee based on the total number of unduplicated automated tests performed.

Number of Tests	Fee		Number of Tests	Fee
1 Test	Lower of the single test or $10.44		17 – 18 Tests	$19.17
2 Tests	$10.44		19 Tests	$22.18
3 –12 Tests	$12.81		20 Tests	$22.89
13 –16 Tests	$17.11		21 Tests	$23.60
			22 –23 Tests	$24.33

Calculating Payment for Panels with Automated and NonAutomated Tests

When panels are comprised of both automated multichannel tests and individual nonautomated tests, they are priced based on:

• The automated multichannel test fee based on the number of tests, added to
• The sum of the fee(s) for the individual nonautomated test(s).

For example CPT® code 80061 is comprised of 2 automated multichannel tests and 1 nonautomated test. As shown below, the fee for 80061 is $27.31.

N/A

CPT® 80061 Component Tests	Number of Automated Tests	Maximum Fee
Automated: CPT® 82465 CPT® 84478	2	Automated: $ 10.44
Nonautomated: CPT® 83718		Nonautomated: $ 16.42
Maximum Payment:		$ 26.86

Calculating Payment for Multiple Panels

When multiple panels are billed or when a panel and individual tests are billed for the same date of service for the same patient, payment will be limited to the total fee allowed for the unduplicated component tests.

Example:
The table below shows how to calculate the maximum payment when panel codes 80050, 80061 and 80076 are billed with individual test codes 82977, 83615, 84439 and 85025.

REPEAT TESTS

Additional payment is allowed for repeat test(s) performed for the same patient on the same day. However, a specimen(s) must be taken from separate encounters.

Test(s) normally performed in a series (for example, glucose tolerance tests or repeat testing of abnormal results) do not qualify as separate encounters.

The medical necessity for repeating the test(s) must be documented in the patient‘s record.

Modifier –91 must be used to identify the repeated test(s). Payment for repeat panel tests or individual components tests will be made based on the methodology described in the Panel Tests section.

SPECIMEN COLLECTION AND HANDLING

Specimen collection charges are allowed as follows:

• The fee is payable only to the provider who actually draws the specimen.
• Payment for the specimen may be made to nursing homes or skilled nursing facilities when an employee qualified to do specimen collection performs the draw.
• Payment for performing the test is separate from the specimen collection fee.
• Costs for media, labor and supplies (for example, gloves, slides, antiseptics, etc.) are included in the specimen collection.
• A collection fee is not allowed when the cost of collecting the specimen(s) is minimal, such as:
  • A throat culture,
  • Pap smear or
  • A routine capillary puncture for clotting or bleeding time.

Specimen collection performed by patients in their homes is not paid (such as stool sample collection).

BILLING TIP: Use CPT® code 36415 for venipuncture. Use HCPCS code P9612 or P9615 for catheterization for collection of specimen.

Complex vascular injection procedures, such as arterial punctures and venisections, are not subject to this policy and will be paid with the appropriate CPT® or HCPCS codes.

Travel will not be paid to nursing home or skilled nursing facility staff that performs specimen collection.

Travel will be paid in addition to the specimen collection fee when all of the following conditions are met:

• It is medically necessary for a provider to draw a specimen from a nursing home, skilled nursing facility or homebound patient, and
• The provider personally draws the specimen, and
• The trip is solely for the purpose of collecting the specimen.

If the specimen draw is incidental to other services, no travel is payable.

BILLING TIP: Use HCPCS code P9603 to bill for actual mileage (1 unit equals 1 mile). HCPCS code P9604 is not covered.

Handling and conveyance will not be paid, (for example, shipping or messenger or courier service of specimen(s)). This includes preparation and handling of specimen(s) for shipping to a reference laboratory. These are considered to be integral to the process and are bundled into the total fee for testing service.

STAT LAB FEES

Usual laboratory services are covered under the Professional Services Fee Schedule. When lab tests are appropriately performed on a STAT basis, the provider may bill HCPCS code S3600 or S3601. Payment is limited to 1 STAT charge per episode (not once per test).

Tests ordered STAT should be limited to only those needed to manage the patient in a true emergency situation. The laboratory report should contain the name of the provider who ordered the STAT test(s). The medical record must reflect the medical necessity and urgency of the service.

The STAT charge will only be paid with the tests listed below.

 

TESTING FOR AND TREATMENT OF BLOODBORNE PATHOGENS

The insurer may pay for post-exposure treatment whenever an injury or probable exposure occurs and there is a potential exposure to an infectious disease. Authorization of treatment in cases of probable exposure (not injury) does not bind the insurer to allowing a claim at a later date.

The exposed worker must apply for benefits (submit an accident report form) before the insurer can pay for testing and treatment.

Covered Testing Protocols

Testing for Hepatitis B, C and HIV should be done at the time of exposure and at 3, 6, and 12 months post exposure. The following test protocols are covered:

Hepatitis B (HBV)

• HbsAg (hepatitis B surface antigen).
• Anti-HBc or HBc-Ab (antibody to hepatitis B core antigen).
• Anti-HBs or HBs-Ab (antibody to hepatitis B surface antigen).

Hepatitis C (HCV)

• Enzyme Immunoassay (EIA).
• Recombinant Immunoblot Assay (RIBA).
• Strip Immunoblot Assay (SIA).

The qualitative reverse transcriptase polymerase chain reaction (RT-PCR) test is the only way to determine whether or not one has active HCV.

The following tests are covered services if HCV is an accepted condition on a claim:

• Quantitative reverse transcriptase polymerase chain reaction (RT-PCR).
• Branched-chain DNA (bDNA).
• Genotyping.
• Liver biopsy.

HIV

There are 2 blood tests needed to verify the presence of HIV in blood:

• Rapid HIV or EIA test, and
• A Western Blot test to confirm seropositive status.

The following tests are used to determine the presence of HIV in blood:

• Rapid HIV test.
• EIA test.
• Western Blot test.
• Immunofluorescent antibody.

The following tests are covered services if HIV is an accepted condition on a claim:

• HIV antiretroviral drug resistance testing.
• Blood count, kidney, and liver function tests.
• CD4 count.
• Viral load testing.

Post-exposure Prophylaxis for HBV

Treatment with hepatitis B immune globulin (HBIG) and the hepatitis B vaccine may be appropriate.

Post-exposure Prophylaxis for HIV

When a possible exposure to HIV occurs, the insurer will pay for chemoprophylaxis treatment in accordance with the most recent Public Health Services (PHS) Guidelines. Prior authorization is not required.

When chemoprophylaxis is administered, the insurer will pay at baseline and periodically during drug treatment for drug toxicity monitoring including:

• Complete blood count and
• Renal and hepatic chemical function tests

Covered Bloodborne Pathogen Treatment Regimens

Chronic hepatitis B (HBV)

• Interferon alfa-2b.
• Lamivudine.

Hepatitis C (HCV) – acute

• Mono therapy.
• Combination therapy.

HIV/AIDS: Covered services are limited to those within the most recent guidelines issued by the HIV/AIDS Treatment Information Service (ATIS). These guidelines are available on the web at http://aidsinfo.nih.gov/.

Treating a Reaction to Testing or Treatment of an Exposure
The insurer will allow a claim and applicable accident fund benefits when a worker has a reaction to covered treatment for a probable exposure.

BLOODBORNE PATHOGEN BILLING CODES