Billing & Coding

OIG Sounds the Alarm on Improper Billing of Lipid Panels & Direct HDL Tests

Medicare could and should have saved over $20 million in payments for medically unnecessary LDL cholesterol blood tests if CMS hadn’t been asleep at the wheel for the past five years. That’s the gist of the message of a new OIG report that compliance managers need to know about, especially if their labs provide such tests for Medicare patients. Here’s a look at the report and what it may portend.

Medicare Coverage of LDL Cholesterol Tests

Medicare Part B covers two basic kinds of cardiovascular-screening blood tests measuring cholesterol and triglyceride levels to detect conditions that may lead to heart attack or stroke:

  • Lipid panels that measure the levels of four lipids in the blood, including total cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol and low-density lipoprotein (LDL) cholesterol, sometimes called “bad cholesterol”; and
  • Direct LDL tests that measure the actual level of LDL in the blood.

The level of LDL cholesterol can also be calculated from the results of the other three tests in the lipid panel. As a result, direct testing for LDL cholesterol generally isn’t separately reimbursable when the lipid panel is performed for the same beneficiary on the same date of service.

Back in April 1, 2003, CMS added the lipid panel (CPT code 80061) and direct LDL test (CPT code 83721) code pair to its National Correct Coding Initiative (NCCI) edits designed to flag codes that shouldn’t be billed together for the same patient at the same time. There are exceptions when it’s okay to bill 80061 together with 83721, in which case the lab must add the -59 modifier. However, the expectation is that these cases will be relatively rare.

The OIG Smells an LDL Cholesterol Billing Rat

In a previous audit, the OIG found that the NCCI edit wasn’t working and that Medicare was still improperly paying for LDL tests and the lipid panel in circumstances where billing both wasn’t justified. It recommended that the CMS tighten up. The purpose of the most recent audit was to determine whether the problem had been solved.

Short answer: No. The OIG audited payments between calendar years 2015 through 2019. Over that four-year period, Medicare Part B made $35.8 million for direct LDL tests to 11,788 providers in addition to lipid panels for the same beneficiary on the same date. After excluding providers with total payments below $500 and interviewing CMS and Medicare Administrative Contractor officials, OIG determined that some providers were billing LDL tests and lipid panels together on a routine basis, i.e., more than 75 percent of the time. Specifically, there were 1,334 such “at-risk providers” accounting for Medicare payments of $20.4 million. After auditing a routine sample, the OIG determined that these payments didn’t satisfy the standards allowing for billing lipid panels and LDL tests on the same patient on the same date.

“CMS’s oversight was not adequate to prevent improper payments for the direct LDL tests,” the OIG concluded. “If CMS had had oversight mechanisms to prevent such payments, Medicare could have saved up to $20.4 million for our audit period.”

The OIG Recommendations

The OIG issued two recommendation that CMS order Medicare contractors to:

  1. Develop oversight mechanisms to identify and prevent improper payments for lipid panel and direct LDL tests to at-risk providers; and
  2. Educate providers on the billing of direct LDL tests in addition to lipid panels.

Perhaps surprisingly, CMS pushed back, indicating that it didn’t agree with the first recommendation. Ordering direct LDL tests and lipid panels together is permissible under Medicare payment rules on the basis of the physician’s clinical judgment, CMS insisted. The agency was only slightly less happy with recommendation two, noting that it already has issued education on correct coding requirements for the proper use of modifiers on claim lines. We maintain that our finding and recommendations are valid. But OIG held its ground, saying that current education does not address this.

Takeaway

OIG reports like these are frequently followed not just by internal system corrections and education, but also stepped-up enforcement action. However, it appears that CMS isn’t going along this time. Foot dragging by CMS might lead OIG to drop the matter, particularly since the dollars involved, i.e., $20.2 million over four years, are so relatively small; on the other hand, the agency may respond by treating the LDL direct tests and lipid panels issue as one that should be primarily pursued at the enforcement level. Stay tuned. . .

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