New Reimbursement Guidelines

NCEP Guidelines, Lipid National Coverage Policy, and Reimbursement; How do these roles affect one another?

The NCEP (National Cholesterol Education Program), recommends that cholesterol be monitored by the measurement of direct LDL cholesterol. Until recently, LDL cholesterol levels were measured by the Friedwald formula, which uses a calculation method involving HDL, Total Cholesterol, and Triglyceride levels. Aside from not being a reimbursable method, the Friedwald formula has shown other limitations; patients are required to fast, the additive variability of the three assays can provide inaccurate and imprecise results, and the calculation method is not suitable for patients with triglyceride levels over 400mg/dl.

The recent availability of simple, accurate, direct measurement assays for LDL cholesterol has made it possible for clinicians to properly monitor and treat their patients with a reliable, precise, and reimbursable method.

The National Coverage Policies for 23 clinical laboratory tests is expected to be published in the Federal Register by the end of first quarter 2001. Once finalized, all Medicare contractors will be required to adopt these coverage policies. One of the 23 National Coverage Policies affected is Lipid Panel testing. This coverage policy will be more aligned with the NCEP guidelines. Listed below is a summary of the new testing frequency included in the policy.

TESTING
FREQUENCY:
1st Year
2nd + Years or once treatment goals have been achieved
LIPID PANEL
CPT Code: 80061
ONCE per year
ONCE per year
TOTAL CHOLESTEROL*
CPT Code: 82465
Six per year
Three per year
HDL CHOLESTEROL*
CPT Code: 83718
DIRECT LDL CHOLESTEROL*
CPT Code: 83721
TRIGLYCERIDES*
CPT Code: 84478
*any combination up to frequency limit