Lipid Profile/Cholesterol Testing

National Government Services recent review of data identified that providers are billing inappropriately for CPTcode 80061, Lipid Panel and CPT 83721, Lipoprotein, direct measurement; LDL cholesterol on the same date of service.

CPT code 83721 was often billed with CPT code 80061 on the same day with modifier -59 and the patient’s triglyceride level was under 400 mg/dl. According to the Local Coverage Determination (LCD) for Lipid Profile/Cholesterol Testing – L27352, it is usually not necessary to perform these tests on the same day unless the triglycerides exceed 400 mg/dl.

The serum LDL concentration may be calculated using the Friedenwald formula (LDL=total cholesterol-HDL-triglcerides/5). This formula is valid only for triglyceride levels less than 400mg/dL. The LDL should be measured directly when the triglyceride level exceeds this value. This calculation may not accurately calculate the LDL in alcoholic patients. These patients may also require direct measurement of the serum LDL.

It is inappropriate to bill claims with CPT 83721 and 80061 on the same day if the patient’s triglycerides are less than 400 mg/dl. Claims will be denied as not medically necessary if these criteria are not met. Documentation of triglycerides > 400 mg/dL on the same sample must be available in the medical record when submitting a claim for direct LDL measurement (83721) when the entire lipid panel 80061 is billed for the same date of service.