Coding for Screening Laboratory Tests

Often we have patients who identify to us that they have coverage for “screening blood work.” This can pose a dilemma for coders and billers due to the coding rules related to reporting screening diagnosis codes. Here are a few things to consider when choosing the code to be used to bill for labs being drawn for a well adult visit.

Has this patient been previously diagnosed with a medical condition that would require you to perform this lab test?  If your answer is yes, then this does not qualify as screening blood work. Use the code associated with the diagnosis (e.g., hyperlipidemia or diabetes or benign essential hypertension) and not a screening code as the primary diagnosis code for the lab tests.

If the provider is seeing a patient for a well adult visit (preventive exam), the provider should bill the well adult visit with the screening diagnosis code V70.0. If the provider also addresses management of chronic conditions at the same encounter, the provider needs to provide appropriate documentation of that chronic disease management and may bill a second evaluation and management code for those separate services. The separate evaluation and management service should be billed with diagnosis codes for the diseases or other medical conditions being addressed.

If lab work is ordered or obtained at this visit and the patient does not have established diseases or other medical conditions then screening diagnosis codes are used. If a patient has an established disease or other condition you can no longer report screening diagnosis codes for blood work related to that condition.  However, you may order screening labs for other conditions that are not related to the underlying chronic conditions. For example, if you have a patient with hypercholesterolemia and Type II diabetes and that patient is coming in for an annual well adult visit, you could order a screening prostate specific antigen (PSA) test on that patient, as that test has nothing to do with the underlying chronic conditions of this patient.  You could not report or order a lipid panel (CPT code 80061) or fasting blood sugar (CPT code 82947) using screening diagnosis codes because the patient has known hypercholesterolemia and Type II diabetes.

Coverage for screening labs is just that- for screening when it is not known if a patient has a condition or not.  Once the diagnosis is established, tests are performed to monitor those conditions and screening diagnosis codes are no longer reported for those conditions.

As billers and coders we need to have a basic understanding of what screening really is.  This has become more complicated because many employer groups have incentives, often called wellness discounts, which provide coverage for routine screening for certain conditions. The employer’s instructions to their employees and to physician’s offices and labs do not always give clear and concise information on when these discounts apply and how to bill for them.  Below is an excerpt of a letter from an employer group to employees on screening services.

“To schedule your screenings, you must make an appointment with your doctor.  In order for your screenings to be covered at no additional cost to you, your doctor must note the codes below when billing our insurance provider”. 

Lipid panel (cholesterol) screening – CPT code 80061

Glucose Blood (fasting) Test- CPT code 82947 or 82948

In the above scenario there is no mention of an associated diagnosis code but upon contacting this employer group, it was made clear that the diagnosis code must be a routine screening diagnosis code.

I would advise coders and billers to contact insurance carriers and employer groups to get clear and concise information when it comes to billing and coding for screening blood work.  Provider representatives should be able to assist you with issues like this, so utilize them for issues related to screening blood work as well as other coding and billing issues that may arise. Often employer groups and payers do not realize that these wellness benefits pose billing and coding problems until providers alert them to these issues.

Below are some of the ICD-9-CM and ICD-10-CM codes used when billing for well adult encounters and screening diagnosis codes versus billing for established medical conditions.