Laboratory Tests Billing Alert: Lipid Panel Test (80061) Completed on the Same Date of Service as an LDL Test (83721)

National Government Services, Inc. Medical Review initiated a review of claims containing both a lipid panel test and direct LDL test completed on the same date of service.

CPT Code Information

The lipid panel testing is commonly used to monitor and regulate lipid-lowering therapy.

CPT code 80061 is the correct code to bill for a lipid panel laboratory test and includes the following three tests:

• 82465 is defined as cholesterol, serum, total
• 83718 is defined as lipoprotein, direct measurement, HDL
• 84478 is defined as triglycerides

CPT code 83721 is the correct code to bill for laboratory testing of the direct measurement of low density lipoprotein (LDL); however, it is not to be used to report a calculated LDL.

CPT code 83721 is a separate test that is not included in the standard lipid panel test (80061). The LDL test may be requested as a follow-up test based on the results of the lipid panel. A physician’s order and documentation of medical necessity is required for Medicare coverage.  

In addition, a recent OIG report (See related content below) states: “The direct LDL test (CPT code 83721) code pair to the NCCI edits. According to the NCCI Coding Policy Manual for Medicare Services (NCCI Coding Policy Manual), there are limited circumstances in which the direct LDL test may be reported on the same date of service as the lipid panel for the same beneficiary (Chapter I, Section O.2 and Chapter X, Section G.1).”

Rational for Noncoverage of a Lipid Panel Test (80061) and an LDL Test (83721) on the Same Date of Service

Once the lipid panel test is completed, the results of the lipid panel can be used to calculate the LDL cholesterol measurement. Direct measurement of LDL cholesterol in addition to total cholesterol (CPT code 82465)or lipid panel (CPT code 80061) may be reasonable and necessary only when the triglyceride level is too high (greater than or equal to 400 mg/dl) to permit calculation of the LDL cholesterol. When reflex testing is necessary, the National Correct Coding Initiative directs that CPT code 83721 be reported with modifier 59.

Medical Review Findings

Review of medical records for claims billed with 80061 and 83721 on the same date of service are frequently denied due to:

• Medical records lack documentation (test results) supporting that a direct LDL measurement lab test was performed. Therefore, 83721 is denied due to insufficient/no medical records to support the billed service.
  • CPT code 83721 is not to be used to report a calculated LDL.
  • Results of the lipid panel test (80061) can be used to calculate the LDL cholesterol  measurement

• Medical records do not support that both services (80061 and 83721) were medically reasonable and necessary.
  • There was no documentation to support the medical necessity for performed 83721 along with 80061. In addition, the lipid panel test results indicate that the triglyceride level is less than 400 mg/d; thus, LDL can be accurately calculated based on the results of the lipid panel test.

Related Content

• Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 80
• CMS IOM Publication 100-03, National Coverage Determinations Manual, Chapter 1, Part 3, Section 190.23 Lipid Testing 
• Office of the Inspector General (OIG) Report, May 2021, Medicare Could Have Saved Up to $20 Million Over 5 Years if CMS Oversight Had Been Adequate to Prevent Payments For Medically Unnecessary Cholesterol Blood Tests
• CMS National Correct Coding Initiative Edits webpage
• NCCI Policy Manual for Medicare
  • Chapter 10 ‒ Pathology / Laboratory Services CPT Codes 80000‒89999

Revised 7/23/2021