Organ or Disease Oriented Panels (Rev. 1451, 07-07-08)

by  Jared Staheli
July 10th, 2015

Organ or disease panels must be paid at the lower of the billed charge, the fee amount for the panel, or the sum of the fee amounts for all components. When panels contain one or more automated tests, the contractor determines the correct price for the panel by comparing the price for the automated profile laboratory tests with the sum of the fee amounts for individual tests. Payment for the total panel may not exceed the sum total of the fee amounts for individual covered tests. All Medicare coverage rules apply.

The Medicare standard systems must calculate the correct payment amount. The CMS furnishes fee prices for each code but the carrier system must compare individual codes billed with codes and prices for related individual tests. (With each HCPCS update, HCPCS codes are reviewed and the system is updated). Once the codes are identified, contractors publish panel codes to providers.

The only acceptable Medicare definition for the component tests included in the CPT codes for organ or disease oriented panels is the American Medical Association (AMA) definition of component tests. The CMS will not pay for the panel code unless all of the tests in the definition are performed. If the laboratory has a custom panel that includes other tests, in addition to those in the defined CPT or HCPCS panels, the additional tests, whether on the list of automated tests or not, are billed separately in addition to the CPT or HCPCS panel code.

NOTE: If a laboratory chooses, it can bill each of the component tests of these panels individually, but payment will be based upon the above rules.

TABLE OF CHEMISTRY PANELS

¹ CPT code 83718 is billed with Organ/Disease Panel 80061 but is not included in the AMCC bundling.

References:

• Pub 100-04 Medicare Claims Processing Manual - Chapter 16