Lipid Panel Testing Coverage Frequency And Under What Conditions?

jdbs3

New Member
I just had a fasting lipid panel in June, 2016; all was very good. My doctor has ordered a re-test for May- 2017. I've pushed back and said Medicare Part B only covers this test every 5 years. And I can not afford to cover the cost out of my own pocket.

However, the doctor's office is telling me that since these are 1) preventative tests, and 2) my current medical problem list, that Medicare will cover it. I'm not convinced.

I've called Medicare? They can't tell me.

So under what conditions is a fasting lipid panel covered? And what frequency?

Thanks,

Signed frustrated
 
This is the reference to the 5 years that I had found

Medicare. According to their website: "Medicare Part B (Medical Insurance) covers screening blood tests for cholesterol, lipid, and triglyceride levels every 5 years."
 
The preventative frequency is once every 5 years. However, the statement "my current medical problem list" sounds like you are "at risk" which would fall under the diagnostic lab test benefit. Diagnostic tests can be performed more frequently but are not "free" (included in the premium). It would be subject to the Part B 20% coinsurance unless you have a Medicare Supplement (Medigap) that covers the coinsurance. Ask your provider if the test would be coded as diagnostic instead of preventative.

"Benefit Category
Diagnostic Laboratory Tests

When monitoring long term anti-lipid dietary or pharmacologic therapy and when following patients with borderline high total or LDL cholesterol levels, it is reasonable to perform the lipid panel annually. A lipid panel at a yearly interval will usually be adequate while measurement of the serum total cholesterol or a measured LDL should suffice for interim visits if the patient does not have hypertriglyceridemia.

Any one component of the panel or a measured LDL may be medically necessary up to six times the first year for monitoring dietary or pharmacologic therapy. More frequent total cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing may be indicated for marked elevations or for changes to anti-lipid therapy due to inadequate initial patient response to dietary or pharmacologic therapy. The LDL cholesterol or total cholesterol may be measured three times yearly after treatment goals have been achieved.

If no dietary or pharmacological therapy is advised, monitoring is not necessary.

When evaluating non-specific chronic abnormalities of the liver (for example, elevations of transaminase, alkaline phosphatase, abnormal imaging studies, etc.), a lipid panel would generally not be indicated more than twice per year."

Reference: https://www.cms.gov/medicare-covera...iod=0&NCDId=102&ncdver=2&bc=AAQAAAAAQEAAAA==&
 
Thank you for your response.

RE: Ask your provider if the test would be coded as diagnostic instead of preventative."

The CPT code is 80061. The ICD-10 code is E78.00. A year ago, I had an LDL of 147; the doctor wanted me to take statins. I decided to see if I could control it with diet. For 6 weeks, I replaced low-fat yogurt with fat yogurt, and gave up all sweets. LDL dropped to 70. This would be a retest that I would take in May, 2017, about 11 months after the last blood test.

Based on this information, is this a diagnostic code that would be covered?
 
ICD-10 E78.00 converts CPT 80061 (Lipid panel) from a preventative test to a diagnostic test that is covered annually. The preventative test combination that is covered every 5 years is ICD-10 Z13.6 billed with 80061.

Medicare Preventative Billing (document page 4, PDF page 6 of 37): https://www.cms.gov/Medicare/Preven...wnloads/MPS-QuickReferenceChart-1TextOnly.pdf

Personally, I would want the tests performed at least 365 days apart. See this thread where a test was denied due to being 9 days short of one year. http://mymedicareforum.com/threads/...cause-a-test-was-performed-9-days-early.9869/
 
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