Today we will discuss coding and coverage issues concerning thyroid testing. Changing clinical usage, new National Coverage Decisions (NCDs) and Correct Coding Initiative (CCI) edits have combined to create some new problems in getting the proper reimbursement for commonly used thyroid tests. As always please feel free to e-mail with questions regarding this newsletter or ideas for future Friday Compliance Briefings.
Charles Root, Ph.D.
Coding and Reimbursement for Thyroid Assays
The following CPT codes are used to report thyroid testing. The 2003 Medicare National Limitation Amount (NLA) is indicated for each procedure.
84436 Thyroxine (T4); total $9.61
84439 Thyroxine, (T4); free $12.60
84443 Thyroid stimulating hormone (TSH) $23.47
84479 Thyroid hormone (T3 or T4) uptake/THBR $9.04
84480 Triiodothyronine (T3); total $19.81
84481 Triiodothyronine (T3); free $23.67
84482 Triiodothyronine (T3); reverse $22.02
Some physicians continue to order obsolete thyroid panels that were deleted from the 2000 CPT, including:
80091: T4 and thyroid uptake
80092: T4, thyroid uptake, and TSH.
These deleted CPT codes are no longer reimbursed, however, the component tests can be ordered separately. Since none of the above tests are considered to be "automated multi-channel tests" by Medicare, payment for multiple tests ordered individually or as a physician designated panel is simply the sum of the individual test payments.
Correct Coding Initiative (CCI) Edits
As of July 3rd, a CCI edit prohibits payment for either total T4 (84436) or T3/T4 uptake (84479) on the same date of service as a free T4 (84439). Unfortunately, this edit cannot be overcome by using a -59 modifier.
Coverage Issues for Thyroid Assays
Current clinical practice guidelines recommend ultrasensitive TSH as the primary assay for the diagnosis of both hyper- and hypothyroidism. TSH may be supplemented by free and total T4, and T3/T4 uptake as follow up tests for patients with confirmed thyroid disease. The medical necessity of using T4 and thyroid uptake rather than the recommended TSH for routine diagnosis of thyroid disease may be questioned by some carriers.
CMS has published a NCD concerning thyroid testing. However, the NCD covers only T4, free T4, TSH and thyroid uptake. Total T3, free T3 or reverse T3 are not part of this NCD.
The NCD recognizes thyroid testing as medically reasonable and necessary to:
Distinguish between primary and secondary hypothyroidism
Confirm or rule out primary hypo- and hyperthyroidism
Monitor thyroid hormone levels, and
Monitor drug therapy for hypothyroidism
Follow-up testing is covered every 6 months in clinically stable patients. More frequent testing may be reasonable and necessary for patients whose therapy has been changed or in whom signs or symptoms of hypo- or hyperthyroidism are noted.
Routine screening of asymptomatic individuals for thyroid disease is not covered by Medicare and probably will not be in the near future. However, the covered symptom codes (for example, malaise and fatigue, weight gain/loss, and symptoms involving cardiovascular and respiratory systems) included in the current NCD allow thyroid tests to be reimbursed for most high-risk patients.