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National
2017 Laboratory Fee Schedule

Effective April 1, 2013 and while sequestration is in effect, all CMS payments for services will be reduced by 2%.
The fees below do not reflect this reduction. Click here for more information.



Disclaimer How To Use This Web Site Advance Beneficiary Notices Frequently Asked Questions
Index:

  • Blood Gases
  • Chemistry
  • Coagulation
  • Cardiac Markers
  • Pregnancy
  • Piccolo-Tests Performed by Waived Laboratories
  • Piccolo-Tests Performed by CLIA Moderate Complexity Laboratories
  • Frequently Asked Questions
    1. What is medical necessity?

    2. How do I bill for tests which I believe will be denied because the patient’s diagnosis is not covered under either national or local coverage policy?

    3. If no local coverage policy exists in my state for ionized calcium, what diagnosis codes are appropriate?

    4. What if ionized calcium is not medically necessary and I don’t want to run it with the other tests on a Chem 8+ cartridge?

    5. How do I bill for additional Hct or glucose tests that are run for the same patient on the same day?

    6. What are automated tests and how do they affect reimbursement for iSTAT tests?

    7. Where can I find the Medicare Regulations governing automated test coding and reimbursement?

    8. Why can't I use the CPT code for a Basic Metabolic Panel (80048) when I run a Chem 8 cartridge?

    9. Can an imaging center bill Medicare for creatinine tests using the I-STAT?

    10. Can I bill for collecting blood when I run tests on the I-STAT?


    What is medical necessity?

    All tests reimbursed by Medicare and most other payers must be medically necessity for the treatment of an injury, illness or malformed body part.

    Medicare uses National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) to define medical necessity. NCDs and LCDs for many clinical tests list the exact diagnosis (ICD-9) codes which will be accepted for payment.

    When neither an NCD or LCD exists, the decision as to what tests are medical necessity for any given patient is left to the judgement of the physician and must be supported by the patient’s medical record.

    For example, no NCD exists for ionized calcium. However, 12 Medicare carriers have published local coverage determinations for ionized calcium.


    How do I bill for tests which I believe will be denied because the patient’s diagnosis is not covered under either national or local coverage policy?

    When an NCD or LCD applies, and the appropriate diagnosis code is not listed as a covered code, a signed Advance Beneficiary Notice (ABN) should be obtained from the patient prior to performing the test. The ABN informs that patient that if the test is denied they are responsible for payment. A properly signed ABN which lists the specific test or service you believe may be denied as well as the reason for probable denial must be obtained in order to bill the patient for a service that is later denied.


    If no local coverage policy exists in my state for ionized calcium, what diagnosis codes are appropriate?

    In states where no LCD for ionized calcium exists, the following list of diagnosis codes commonly associated with ionized calcium may be used as a reference. Remember that the diagnosis must always be medically necessary and supported by the patient’s medical record.

    038.8 Other specified septicemias
    038.9 Unspecified septicemia
    242.90 Thyrotoxicosis without of goiter or other cause without thyrotoxic crisis or storm
    242.91 Thyrotoxicosis without goiter or other cause with mention of thyrotoxic crisis or storm
    252.00 Hyperparathyroidism, unspecified
    252.01 Primary hyperparathyroidism
    252.02 Secondary hyperparathyroidism, non-renal
    252.08 Other hyperparathyroidism
    252.1 Hypoparathyroidism
    252.8 Other specified disorders of parathyroid gland
    252.9 Unspecified disorder of parathyroid gland
    259.3 Ectopic hormone secretion, not elsewhere classified
    268.0 Rickets, active
    268.1 Rickets, late effect
    268.2 Osteomalacia, unspecified
    268.9 Unspecified vitamin D deficiency
    273.8 Other disorders of plasma protein metabolism
    275.2 Disorders of magnesium metabolism
    275.40 Disorders of calcium metabolism, unspecified
    275.41 Hypocalcemia
    275.42 Hypercalcemia
    275.49 Other disorders of calcium metabolism
    276.2 Acidosis
    276.3 Alkalosis
    276.4 Mixed acid-base balance disorder
    276.50 Volume depletion, unspecified
    276.51 Dehydration
    276.52 Hypovolemia
    276.6 Fluid overload
    276.9 Electrolyte and fluid disorders not elsewhere classified
    278.4 Hypervitaminosis D
    427.5 Cardiac arrest
    458.9 Hypotension, unspecified
    571.5 Cirrhosis of liver without mention of alcohol
    571.6 Biliary cirrhosis
    577.0 Acute pancreatitis
    577.1 Chronic pancreatitis
    579.0 Celiac disease
    579.1 Tropical sprue
    579.2 Blind loop syndrome
    579.3 Other and unspecified postsurgical nonabsorption
    579.4 Pancreatic steatorrhea
    579.8 Other specified intestinal malabsorption
    579.9 Unspecified intestinal malabsorption
    584.5 Acute renal failure with lesion of tubular necrosis
    584.6 Acute renal failure with lesion of renal cortical necrosis
    584.7 Acute renal failure with lesion of renal medullary [papillary] necrosis
    584.8 Acute renal failure with other specified pathological lesion in kidney
    584.9 Acute renal failure, unspecified
    585.1 Chronic kidney disease, Stage I
    585.2 Chronic kidney disease, Stage II (mild)
    585.3 Chronic kidney disease, Stage III (moderate)
    585.4 Chronic kidney disease, Stage IV (severe)
    585.5 Chronic kidney disease, Stage V
    585.6 End stage renal disease
    585.9 Chronic kidney disease, unspecified
    586 Renal failure, unspecified
    587 Renal sclerosis, unspecified
    588.0 Renal osteodystrophy
    588.81 Secondary hyperparathyroidism (of renal origin)
    588.89 Other specified disorders resulting from impaired renal function
    588.9 Unspecified disorder resulting from impaired renal function
    729.82 Cramp referable to limbs
    733.00 Osteoporosis, unspecified
    733.01 Senile osteoporosis
    733.02 Idiopathic osteoporosis
    733.03 Disuse osteoporosis
    733.09 Other osteoporosis
    733.90 Disorder of bone and cartilage, unspecified
    775.4 Hypocalcemia and hypomagnesemia of newborn
    775.7 Late metabolic acidosis of newborn
    775.9 Unspecified endocrine and metabolic disturbances specific to the fetus and newborn
    780.31 Febrile convulsions
    780.39 Other convulsions
    780.6 Fever
    780.71 Chronic fatigue syndrome
    780.79 Other malaise and fatigue
    781.0 Abnormal involuntary movements
    781.7 Tetany
    785.0 Tachycardia, unspecified
    786.06 Tachypnea
    787.01 Nausea with vomiting
    787.02 Nausea alone
    787.03 Vomiting alone
    787.2 Dysphagia
    788.42 Polyuria
    789.06 Abdominal pain, epigastric
    996.81 Complications, transplanted kidney
    996.83 Complications, transplanted heart
    V42.0 Organ or tissue replaced by transplant, kidney
    V42.1 Organ or tissue replaced by transplant, heart
    V42.84 Organ or tissue replaced by transplant, intestines
    V45.1 Renal dialysis status
    V56.0 Extracorporeal dialysis


    What if ionized calcium is not medically necessary and I don’t want to run it with the other tests on a Chem 8+ cartridge?

    An ionized calcium test should not be performed and billed if it is not medically necessary. The ionized test function can be “turned off” when running an iSTAT Chem 8+ cartridge so that no test result is reported. See your Operator’s Manual for how to do this.


    How do I bill for additional Hct or glucose tests are run for the same patient on the same day?

    Repeat tests performed on the same day (date of service) must be identified by using the CPT codifier –59 with the appropriate test code. This modifier indicates that the test is a separate and distinct medically necessary service and not a duplicate test.


    Why can't I use the CPT code for a Basic Metabolic Panel (80048) when I run a Chem 8 cartridge?

    Answer: CPT code 80048 (Basic Metabolic Panel, total calcium) can be used only when each of the following eight tests are performed: total calcium, carbon dioxide, chloride, creatinine, glucose, potassium, sodium and BUN. The Chem 8 cartridge measures ionized calcium, not total calcium; thus CPT code 80047 (Basic Metabolic Panel, ionized calcium) must be used. Effective July 1, 2008, reimbursement for 80047 will be the same as for 80048.


    Can an imaging center bill Medicare for creatinine tests using the I-STAT?

    Answer: Yes. You will need a CLIA Certificate of Waiver or CLIA Moderate or High Complexity Certificate. Be sure to include your CLIA number in Item 23 of the CMS 1500 form (or its electronic equivalent). The test is billed using CPT code 82565 (Creatinine, blood) with a QW modifier. Since there is no co-pay for clinical laboratory tests, you will receive the entire fee schedule amount, the patient pays nothing.


    Can I bill for collecting blood when I run tests on the I-STAT?

    Answer: Medicare pays $3.00 for blood collection by venipuncture. Use CPT code 36415. (Collection of venous blood by venipuncture). Only one specimen collection fee is allowed, no matter how many tubes are drawn or how many different tests are performed on the specimen. Capillary blood collection is reported using 36416 (Collection of capillary blood specimen (e.g., finger, heel, ear stick).  Medicare does not cover capillary blood collection, however, some private payers do.


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