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2016 Lab Fee Schedule Updated     


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Q3 2016 ASP Drug Pricing Updated     


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LCD Database Current Through 09/19/2016     

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Laboratory Fee Schedule

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80051
Quick jump to procedure code: Printer Friendly Version
80055

CPT® 80053: COMPREHENSIVE METABOLIC PANEL THIS PANEL MUST INCLUDE THE FOLLOWING: ALBUMIN (82040) BILIRUBIN, TOTAL (82247) CALCIUM, TOTAL (82310) CARBON DIOXIDE (BICARBONATE) (82374) CHLORIDE (82435) CREATININE (82565) GLUCOSE (82947) PHOSPHATASE, ALKALINE (84075) POTASSIUM (84132) PROTEIN, TOTAL (84155) SODIUM (84295) TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) UREA NITROGEN (BUN) (84520)

Short Description: Comprehen metabolic panel

--

CPT copyright 2015 American Medical Association. All rights reserved.


Medicare Reimbursement Information         Hide this section.

ALABAMA-Entire State
ALASKA-Entire State
ARIZONA-Entire State
ARKANSAS-Entire State
CALIFORNIA NORTH-Marin/Napa/Solano
CALIFORNIA NORTH-San Francisco
CALIFORNIA NORTH-San Mateo
CALIFORNIA NORTH-Oakland/Berkeley
CALIFORNIA NORTH-Santa Clara
CALIFORNIA NORTH-Rest of North California
CALIFORNIA SOUTH-Ventura
CALIFORNIA SOUTH-Los Angeles
CALIFORNIA SOUTH-Anaheim/Santa Ana
CALIFORNIA SOUTH-Rest of South California
COLORADO-Entire State
CONNECTICUT-Entire State
DELAWARE-Entire State
DIST of COL-DC + MD/VA Suburbs
FLORIDA-Ft Lauderdale
FLORIDA-Miami
FLORIDA-Rest of Florida
GEORGIA-Atlanta
GEORGIA-Rest of Georgia
HAWAII/GUAM-Entire State/Terr.
IDAHO-Entire State
ILLINOIS-East St. Louis
ILLINOIS-Suburban Chicago
ILLINOIS-Chicago
ILLINOIS-Rest of Illinois
INDIANA-Entire State
IOWA-Entire State
KANSAS-Entire State
KENTUCKY-Entire State
LOUISIANA-New Orleans
LOUISIANA-Rest of Louisiana
MAINE-Southern Maine
MAINE-Rest of Maine
MARYLAND-Baltimore and suburbs
MARYLAND-Rest of Maryland
MASSACHUSETTS-Boston
MASSACHUSETTS-Rest of Massachusetts
MICHIGAN-Detroit
MICHIGAN-Rest of Michigan
MINNESOTA-Entire State
MISSISSIPPI-Entire State
MISSOURI-Kansas City
MISSOURI-St. Louis
MISSOURI-Rest of Missouri
MONTANA-Entire State
NEBRASKA-Entire State
NEVADA-Entire State
NEW HAMPSHIRE-Entire State
NEW JERSEY-Northern NJ
NEW JERSEY-Rest of New Jersey
NEW MEXICO-Entire State
NEW YORK-Manhattan
NEW YORK-NYC Suburbs/LI
NEW YORK-Poughkpsie/No NYC Sub
NEW YORK-Rest of New York
NEW YORK-Queens
NORTH CAROLINA-Entire State
NORTH DAKOTA-Entire State
OHIO-Entire State
OKLAHOMA-Entire State
OREGON-Portland
OREGON-Rest of Oregon
PENNSYLVANIA-Philadelphia
PENNSYLVANIA-Rest of Pennsylvania
PUERTO RICO-Entire Territory
RHODE ISLAND-Entire State
SOUTH CAROLINA-Entire State
SOUTH DAKOTA-Entire State
TENNESSEE-Entire State
TEXAS-Brazoria
TEXAS-Dallas
TEXAS-Galveston
TEXAS-Houston
TEXAS-Beaumont
TEXAS-Fort Worth
TEXAS-Austin
TEXAS-Rest of Texas
UTAH-Entire State
VERMONT-Entire State
VIRGIN ISLANDS-Entire State
VIRGINIA-Entire State
WASHINGTON-Seattle (King County)
WASHINGTON-Rest of Washington
WEST VIRGINIA-Entire State
WISCONSIN-Entire State
WYOMING-Entire State
2016 Laboratory Fee Schedule: $14.39

Revenue Code(s):
301-Laboratory-chemistry



2016 OPPS Status Indicator: Q4

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

Commonly Associated Diagnosis Codes*            Hide this section.
PercentageICD-9ICD-10 Conversions
8.9% V58.69    Long-term (current) use of other medications Z79.891   Long term (current) use of opiate analgesic
OR:
Z79.899   Other long term (current) drug therapy
6.3% 272.4    Other and unspecified hyperlipidemia E78.4   Other hyperlipidemia
OR:
E78.5   Hyperlipidemia, unspecified
4.5% 401.9    Unspecified hypertension I10   Essential (primary) hypertension
4.5% 250.00    Diabetes mellitus without complication, type II or unspecified type, not stated as uncontrolled E11.9   Type 2 diabetes mellitus without complications
4.2% 401.1    Benign hypertension I10   Essential (primary) hypertension
3.3% 780.79    Other malaise and fatigue G93.3   Postviral fatigue syndrome
OR:
R53.1   Weakness
OR:
R53.81   Other malaise
OR:
R53.83   Other fatigue
3.2% 272.0    Pure hypercholesterolemia E78.0   Pure hypercholesterolemia
3.1% 244.9    Unspecified hypothyroidism E03.9   Hypothyroidism, unspecified
2.8% 285.9    Anemia, unspecified D64.9   Anemia, unspecified
2.2% V76.44    Special screening for malignant neoplasms, prostate Z12.5   Encounter for screening for malignant neoplasm of prostate

* Commonly Associated ICD-10 codes derived from 2010 Physician Supplier Part B Medicare claims data and 2015 CMS General Equivalency Mapping Codes (GEM).
This data represents an analysis of 43 million claims processed for 1.7 million beneficiaries in 2010.

Medicare Coverage Policy Information         Hide this section.
No contractor selected.

80053 not found in an Local Coverage Determination (LCD) for your contractor. No other coverage policies found in database.

CCI and MUE Edits*         Hide this section.

CCI Edits for 80053
Denied Codes (1)
Effective
Modifier
Accepted (2)
80047 Metabolic panel ionized ca
01/01/2008 Yes
80048 Metabolic panel total ca
06/05/2000 No
80051 Electrolyte panel
07/01/2001 Yes
80069 Renal function panel
07/01/2001 No
80076 Hepatic function panel
06/05/2000 No
82040 Assay of serum albumin
06/05/2000 Yes
82247 Bilirubin total
06/05/2000 Yes
82310 Assay of calcium
06/05/2000 Yes
82374 Assay blood carbon dioxide
06/05/2000 Yes
82435 Assay of blood chloride
06/05/2000 Yes
 
Denied Codes (1)
Effective
Modifier
Accepted (2)
82565 Assay of creatinine
06/05/2000 Yes
82947 Assay glucose blood quant
06/05/2000 Yes
84075 Assay alkaline phosphatase
06/05/2000 Yes
84132 Assay of serum potassium
06/05/2000 Yes
84155 Assay of protein serum
06/05/2000 Yes
84295 Assay of serum sodium
06/05/2000 Yes
84450 Transferase (ast) (sgot)
06/05/2000 Yes
84460 Alanine amino (alt) (sgpt)
06/05/2000 Yes
84520 Assay of urea nitrogen
06/05/2000 Yes
(1) These codes will be denied when submitted for payment on the same date of service as 80053.

(2) "Yes" indicates that the use of a modifier with the denied code will overcome the edit and allow payment.
"No" indicates that the second code will always be denied.


Medically Unlikely Edits for 80053


Practitioner
Hospital Outpatient
DME Supplier
Allowed Frequency per Day: 1 1 Not Listed
Adjudication Indicator: 3 Date of Service Edit: Clinical 3 Date of Service Edit: Clinical Not Listed
Rationale: CMS Policy CMS Policy Not Listed

* The responsibility for the content of any "National Correct Coding Policy" included in this product is with the Centers for Medicare and Medicaid Services and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, nonuse, or interpretation of information contained in this product.


   80053 Top 5 Ordering Providers National*
MICHAEL VALACHOVIC -DALLAS,TX 66,101
FRANCIS VARGA -SPRINGFIELD,MO 33,409
OTIS ENGELMAN -SUMMERVILLE,SC 31,570
JON KELLER -PALO ALTO,CA 31,246
PATRICIA HANSEN -LOUISVILLE,KY 23,408

   80053 Top 5 Ordering Organizations National*
LABORATORY CORPORATION OF AMERICA HOLDINGS-NC 1,108,878
LABORATORY CORPORATION OF AMERICA HOLDINGS-NJ 809,827
QUEST DIAGNOSTICS CLINICAL LABORATORIES INC-FL 676,849
LABORATORY CORPORATION OF AMERICA HOLDINGS-AL 660,323
LABORATORY CORPORATION OF AMERICA HOLDINGS-OH 627,354

*Based on 2014 Medicare Fee-For Service Provider Utilization & Payment Data, Physician and Other Supplier, Public Use File



   Medicare Part B Utilization Data for 80053*         Hide this section.


Annual Procedures / Tests Performed / Denied


Total National Services (all modifiers) Submitted 2015: 30,718,768
Total Services Denied 2015: 2,228,924 (7.3%)
National Charges Submitted 2015: $1,606,342,902.00
National Charges Allowed 2015: $316,746,111.00
National Average (No Modifier) Fee Submitted 2015: $ 52.03
National Average (No Modifier) Fee Allowed 2015: $ 11.05
National Average (26) Fee Submitted 2015: $ 33.99
National Average (26) Fee Allowed 2015: $ 0.00
National Average (QW) Fee Submitted 2015: $ 54.76
National Average (QW) Fee Allowed 2015: $ 12.13
National Average (TC) Fee Submitted 2015: $ 88.09
National Average (TC) Fee Allowed 2015: $ 0.00


Top 5 Performing Specialties 2015 Total Tests Percent
of Total
Average
Amount
Submitted
Denials Percent
Denied
Clinical laboratory
(billing independently)
22,562,167 73.4% $ 53.54 1,806,618 8.0%
Internal medicine 2,572,830 8.4% $ 46.69 120,328 4.7%
Family practice 1,791,659 5.8% $ 47.30 117,976 6.6%
Hematology/oncology
(eff 5/92)
1,511,743 4.9% $ 51.22 58,818 3.9%
Medical oncology
(eff 5/92)
465,162 1.5% $ 51.36 15,606 3.4%

Top 5 Places of Service 2015 Total Tests Percent
of Total
Average
Amount
Submitted
Denials Percent
Denied
Independent laboratory 22,212,408 72.3% $ 53.54 1,754,446 7.9%
Office 8,208,126 26.7% $ 49.38 399,627 4.9%
Nursing facility 167,592 0.5% $ 35.10 45,220 27.0%
Skilled nursing facility 42,225 0.1% $ 36.05 7,863 18.6%
Urgent Care Facility (eff. 1/1/03) 26,440 0.1% $ 59.14 4,024 15.2%

Top 5 Modifiers Submitted 2015 Total Tests Percent
of Total
Average
Amount
Submitted
Denials Percent
Denied
No Modifier 28,247,155 92.0% $ 52.03 2,031,113 7.2%
QW - CLIA Waived Category Test 1,042,314 3.4% $ 54.76 71,301 6.8%
90 - Reference (Outside) Laboratory 629,934 2.1% $ 51.74 77,878 12.4%
GA - Advanced Beneficiary Notice (ABN) on File 304,114 1.0% $ 49.61 14,509 4.8%
QP - Documentation is on file showing that the lab test(s) was ordered individually or ordered as a CPT recognized panel other than automated profile codes 200,921 0.7% $ 85.24 15,473 7.7%

Click here for more information on Custom CodeMap Medicare Utililation Reports.


*Utilization data is derived from analysis of the Physician Supplier Procedure Summary Master File (PSPSMF) which includes data from all Medicare Part B carriers. This data represents procedure-specific billing data for all physician/supplier services rendered to all Medicare beneficiaries during the calendar year named and processed by the Carriers through the six months of the following year.

Part B charge and utilization data for institutional services (hospital outpatient departments, home health agencies, comprehensive outpatient rehabilitation facilities, end-stage renal disease facilities, and rural health clinics) are processed by Medicare Part A fiscal intermediaries and are not included in this data. Data for services rendered to beneficiaries enrolled in risk-based Health Maintenance Organizations (HMOs) are also not included.


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09/27/2016 08:50:10 54.196.145.173

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