APPENDIX E
1998 Medicare Carrier Denial Rates



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Medicare Laboratory Payment Policy: Now and in the Future APPENDIX E 1998 Medicare Carrier Denial Rates

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Medicare Laboratory Payment Policy: Now and in the Future TABLE E.1 1998 Medicare Carrier Denial Rates for Top 100 CPT Codes Obs. No. CPT Description Total Claims Allowed Services Denied Claims Percent Denied 1 G0001 Venipuncture 54,308,311 50,522,357 3,785,954 7 2 80061 Lipid panel 10,012,394 8,112,908 1,899,486 19 3 85025 Automated hemogram 13,484,091 10,641,281 2,842,810 21 4 84443 Assay TSH 5,871,658 4,579,775 1,291,883 22 5 80054 Comp metabolic panel 10,290,202 9,491,333 798,869 8 6 85024 Automated hemogram 8,662,269 7,358,832 1,303,437 15 7 84153 Assay of PSA, total 4,756,531 3,284,409 1,472,122 31 8 80092 Thyroid panel w/TSH 2,534,185 1,974,563 559,622 22 9 85610 Prothombin time 14,291,139 12,574,088 1,717,051 12 10 83036 Glycated hemoglobin test 5,066,357 4,162,652 903,705 18 11 80049 Metabolic panel, basic 5,828,554 5,468,084 360,470 6 12 81000 Urinalysis, nonauto w/scope 10,333,195 9,197,005 1,136,190 11 13 87086 Urine culture/colony count 3,470,828 2,977,871 492,957 14 14 83970 Assay of parathormone 607,387 563,481 43,906 7 15 88342 Immunocytochemistry 773,537 679,395 94,142 12 16 80162 Assay of digoxin 2,217,224 1,719,286 497,938 22 17 82607 Vitamin B-12 1,293,984 1,148,163 145,821 11 18 82728 Assay of ferritin 1,676,425 1,206,352 470,073 28 19 82947 Assay of glucose, quant 6,808,196 5,095,476 1,712,720 25 20 83718 Assay of lipoprotein 2,735,590 1,971,582 764,008 28 21 80058 Hepatic function panel 3,257,316 2,793,817 463,499 14 22 83550 Iron-binding test 2,222,641 1,672,426 550,215 25 23 83540 Assay of iron 3,125,180 2,065,183 1,059,997 34 24 85023 Automated hemogram 1,679,112 1,482,497 196,615 12 25 87186 Antibiotic sensitivity, mic 1,541,216 1,423,826 117,380 8 26 88312 Special stains 750,231 691,029 59,202 8 27 82746 Blood folic acid serum 912,478 791,881 120,597 13 28 80185 Assay of phenytoin, total 839,618 778,174 61,444 7

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Medicare Laboratory Payment Policy: Now and in the Future 29 87340 Hep B surface antigen, EIA 1,066,065 990,005 76,060 7 30 82378 Carcinoembryonic antigen 717,046 523,034 194,012 27 31 88180 Cell marker study 765,834 578,032 187,802 25 32 87088 Urine bacteria culture 1,421,349 1,208,672 212,677 15 33 81001 Urinalysis, auto w/scope 3,123,900 2,832,521 291,379 9 34 82108 Assay of aluminum 374,227 347,575 26,652 7 35 83721 Assay of blood lipoprotein 1,016,926 890,414 126,512 12 36 85651 RBC sed rate, nonautomated 2,852,933 2,382,302 470,631 16 37 84439 Assay of free thyroxine 1,043,574 875,160 168,414 16 38 81002 Urinalysis nonauto w/o scope 3,672,390 3,040,808 631,582 17 39 84132 Assay of serum potassium 3,228,326 2,903,922 324,404 10 40 85027 Automated hemogram 1,347,928 1,117,113 230,815 17 41 80051 Electrolyte panel 1,686,997 1,564,619 122,378 7 42 84460 Alanine (alt) (SGPT) 4,473,439 4,022,030 451,409 10 43 82565 Assay of creatine 3,690,794 3,361,129 329,665 9 44 83735 Assay of magnesium 1,658,816 1,051,152 607,664 37 45 84436 Assay of total thyroxine 1,328,819 967,532 361,287 27 46 87070 Culture specimen, bacteria 795,903 732,725 63,178 8 47 88313 Special stains 714,671 644,559 70,112 10 48 82270 Test for blood, feces 3,582,984 2,406,732 1,176,252 33 49 84480 Assay, triiodothyronine (t3) 478,533 427,966 50,567 11 50 86038 Antinuclear, antibodies 490,385 449,731 40,654 8 51 86235 Nuclear antigen antibodies 355,112 310,794 44,318 12 52 80059 Hepatitis panel 111,194 89,049 22,145 20 53 84165 Assay of serum proteins 478,051 441,159 36,892 8 54 82962 Glucose blood test 2,025,904 1,624,456 401,448 20 55 83615 Lactate (LD) (LDH) enzyme 3,590,958 3,229,463 361,495 10 56 82465 Assay of serum cholesterol 3,796,842 2,545,361 1,251,481 33 57 84550 Assay of blood uric acid 3,631,496 3,269,558 361,938 10 58 80164 Assay, dipropylaoctic acid 384,222 358,712 25,510 7 59 86316 Immunoassay, tumor antigen 380,049 230,267 149,782 39

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Medicare Laboratory Payment Policy: Now and in the Future Obs. No. CPT Description Total Claims Allowed Services Denied Claims Percent Denied 60 84520 Assay of urea nitrogen 3,142,103 2,829,708 312,395 10 61 84134 Assay of prealbumin 369,369 337,573 31,796 9 62 80091 Thyroid panel 494,986 341,512 153,474 31 63 87184 Antibiotic sensitivity, each 710,761 662,935 47,826 7 64 84466 Assay of transferrin 412,205 368,777 43,428 11 65 85021 Automated hemogram 945,869 785,785 160,084 17 66 88311 Decalcify tissues 521,382 476,714 44,668 9 67 84450 Transfarase (AST) (SGOT) 2,472,065 2,207,233 264,832 11 68 84403 Assay of total testosterone 182,640 166,282 16,358 9 69 80198 Assay of theophylline 316,372 296,049 20,323 6 70 85730 Thromboplastin time, partial 1,011,362 672,243 339,119 34 71 84100 Assay of phosphrus 3,277,539 2,945,742 331,797 10 72 88358 Analysis, tumor 45,022 33,684 11,338 25 73 82784 Assay of gammaglobulin IGM 475,411 443,826 31,585 7 74 80156 Assay of carbamazepine 290,031 270,482 19,549 7 75 87536 HIV-1 DNA, guant 61,753 50,847 10,906 18 76 88156 Cytopath cerv/vag tbs 1,123,563 705,034 418,529 37 77 p3000 Screen Pap by tech w md spuv   696,620     78 86677 Helicobacter pylori 294,970 261,064 33,906 11 79 87163 Special microbiology culture 365,712 332,893 32,819 9 80 85022 Automated hemogram 721,987 625,796 96,191 13 81 86706 Hepatitis B surface antibody 318,970 291,801 27,169 9 82 82977 Assay of GGT 2,710,498 1,776,256 934,242 34 83 82985 Glycated protein 267,351 207,433 59,918 22 84 82310 Assay of calcium 1,835,714 1,627,676 208,038 11 85 84478 Assay of triglycerides 2,325,893 1,547,433 778,460 33 86 82150 Assay of amylase 522,595 457,640 64,955 12 87 81003 Urinalysis, auto w/o scope 1,524,186 1,304,784 219,402 14

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Medicare Laboratory Payment Policy: Now and in the Future 88 80100 Drug screen 236,133 206,622 29,511 12 89 86803 Hepatitis c ab test 221,837 198,565 23,272 10 90 80101 Drug screen 281,363 242,105 39,258 14 91 82131 Amino acids, single quant 200,511 166,743 33,768 17 92 85045 Reticulocyte count 718,565 643,016 75,549 11 93 82550 Assay of CK (CPK) 992,983 888,071 104,912 11 94 88346 Immunofluorescent study 100,003 87,556 12,447 12 95 86003 Allergen specific ige 642,755 537,312 105,443 16 96 G0107 CA screen fecal blood test   909,427     97 84295 Assay of serum sodium 1,605,560 1,449,005 156,555 10 98 86334 Immunofixation procedure 112,513 103,770 8,743 8 99 85007 Differential WBC Count 677,050 590,005 87,045 13 100 80158 Assay of cyclosporine 122,397 109,266 13,131 11     AVERAGE 266,287,495 228,699,563 39,193,969 15 NOTE: The committee was unable to obtain an explanation for the denials. Since many of the tests with high denial rates are not screening tests, this does not fully explain the high denial rates. Other possible reasons for claims denials include stringent local medical review policies, contractors’ inability to match ICD-9 codes with the appropriate CPT codes due to flaws in their computer programs, duplicative bills for a claim that was already paid, the patient is not eligible for benefits, the provider is not an approved Medicare provider, or the provider is billing for a type of test that is outside the laboratory’s CLIA certification level. There appears to be no obvious pattern to the denial rates. One test that has a high rate of denial in one carrier region will have a very low denial rate in another carrier region. AST = aspartate transominase; CK = creatine kinase; CPK = creatine phosphokinase; CPT = Current Procedural Terminology; EIA = enzyme immunoassay; GGT = γ-glutamyl transferase; MIC = minimum inhibitory concentration; PSA = prostate-specific antigen; RBC = red-blood cell; SGOT = serum glutamic-oxalvacetic transaminase; SGPT = serum glutamic-pyruvic transaminase; TSH = thyroid-stimulating hormone; WBC = white-blood cell.

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Medicare Laboratory Payment Policy: Now and in the Future TABLE E.2 1998 Medicare Carrier Denial Rates for the Top 20 Clinical Laboratory Tests, by State     Denial Rate (percentage)     510 511 520 521 522 528 590 621 623 CPT Code Description AL GA AR NM OK LA FL IL MI G0001 Venipuncture 5 7 5 8 6 7 7 7 5 80061 Lipid panel 14 17 5 25 14 16 15 23 17 85025 Automated hemogram 27 35 5 29 5 17 14 34 35 84443 Assay TSH 19 26 23 30 17 30 26 8 7 80054 Comp metabol panel 6 8 5 6 4 6 6 9 6 85024 Automated hemogram 18 16 4 6 8 13 12 19 19 84153 Assay of PSA, totala 41 33 53 32 11 50 41 29 30 80092 Thyroid panel w/TSHb 25 8 30 20 14 27 21 22 8 85610 Prothrombin time 9 12 4 14 12 12 13 15 15 83036 Glycated hemoglobin test 14 20 13 20 14 19 17 17 18 80049 Metabolic panel, basic 4 6 4 5 3 4 5 7 4 81000 Urinalysis, nonauto w/scope 20 16 13 7 12 5 8 9 6 87086 Urine culture/colony count 12 18 6 7 3 18 15 23 19 83970 Assay of parathormone 4 28 3 8 4 9 5 5 6 88342 Immunocytochemistry 21 6 12 33 25 12 10 31 21 80162 Assay of digoxin 30 49 26 17 12 22 24 47 53 82607 Vitamin B-12 5 6 6 6 3 8 6 9 6 82728 Assay of ferritin 32 33 53 38 17 55 9 15 17 82947 Assay of glucose, quant 25 27 21 14 8 19 29 26 39 83718 Assay of lipoprotein 19 27 7 45 29 37 34 40 41 80058 Hepatic function panel 48 46 6 5 4 47 5 7 4

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Medicare Laboratory Payment Policy: Now and in the Future     Denial Rate (percentage)     630 640 650 655 660 740 751 801 803 CPT Code Description IN IA KS NE KY MO MT NY(W) NY(E) G0001 Venipuncture 7 4 2 3 5 4 32 7 12 80061 Lipid panel 15 9 23 25 15 34 19 7 20 85025 Automated hemogram 7 5 5 9 31 5 65 12 33 84443 Assay TSH 38 16 9 11 21 15 39 24 33 80054 Comp metabol panel 7 10 3 6 10 5 16 6 11 85024 Automated hemogram 9 7 3 6 14 4 29 6 27 84153 Assay of PSA, totala 54 46 30 30 26 36 41 46 46 80092 Thyroid panel w/TSHb 39 15 12 10 23 15 34 20 26 85610 Prothrombin time 16 2 7 6 43 9 34 12 21 83036 Glycated hemoglobin test 17 3 8 9 5 12 41 19 39 80049 Metabolic panel, basic 6 5 3 3 7 3 24 4 10 81000 Urinalysis, nonauto w/scope 6 13 4 5 12 7 38 14 22 87086 Urine culture/colony count 5 7 6 14 7 11 44 21 24 83970 Assay of parathormone 8 10 6 75 7 6 13 12 58 88342 Immunocytochemistry 7 11 5 8 23 7 1 7 10 80162 Assay of digoxin 17 2 12 12 7 13 33 21 30 82607 Vitamin B-12 10 42 3 5 8 4 43 18 20 82728 Assay of ferritin 49 19 24 23 33 26 62 42 46 82947 Assay of glucose, quant 12 9 17 16 27 20 22 43 41 83718 Assay of lipoprotein 17 14 46 40 17 34 68 34 28 80058 Hepatic function panel 6 4 3 4 15 4 15 4 9

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Medicare Laboratory Payment Policy: Now and in the Future     Denial Rate (percentage)     820 824 825 831 832 833 834 835 836 860 CPT Code Description N/SD CO WY AK AZ HI NV OR WA NJ G0001 Venipuncture 4 10 7 4 12 4 10 5 6 4 80061 Lipid panel 8 23 15 16 33 7 26 14 6 29 85025 Automated hemogram 5 17 7 10 21 14 12 8 6 5 84443 Assay TSH 17 32 23 24 41 19 36 25 27 16 80054 Comp metabol panel 5 15 7 5 17 11 9 5 5 4 85024 Automated hemogram 7 8 9 15 6 10 6 12 7 6 84153 Assay of PSA, totala 53 54 46 36 33 20 35 26 27 21 80092 Thyroid panel w/TSHb 15 29 17 24 31 19 27 16 20 13 85610 Prothrombin time 5 14 9 10 24 13 24 10 14 10 83036 Glycated hemoglobin test 6 22 12 26 31 17 29 18 5 29 80049 Metabolic panel, basic 4 11 4 6 13 11 12 4 5 3 81000 Urinalysis, nonauto w/scope 12 25 15 7 9 10 21 8 7 10 87086 Urine culture/colony count 10 19 12 7 11 4 7 5 5 15 83970 Assay of parathormone 6 12 5 0 21 14 12 4 9 5 88342 Immunocytochemistry 5 12 11 40 14 5 3 4 9 8 80162 Assay of digoxin 1 13 7 4 15 4 8 4 5 20 82607 Vitamin B-12 50 57 49 3 20 4 11 6 6 5 82728 Assay of ferritin 24 46 39 28 47 17 38 24 32 46 82947 Assay of glucose, quant 10 24 12 22 48 26 44 28 10 25 83718 Assay of lipoprotein 12 42 23 33 36 18 36 23 7 19 80058 Hepatic function panel 5 10 6 19 66 9 75 24 5 4

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Medicare Laboratory Payment Policy: Now and in the Future     Denial Rate (percentage)     865 870 880 900 901 902 903 910 951 973 CPT Code Description PA RI SC TX MD DE DC UT WI PR/VI G0001 Venipuncture 4 15 6 5 6 18 5 7 4 6 80061 Lipid panel 20 16 34 13 13 19 27 25 13 7 85025 Automated hemogram 5 34 19 33 33 39 37 36 25 6 84443 Assay TSH 12 27 31 24 25 35 27 48 18 9 80054 Comp metabol panel 4 10 9 6 7 16 5 12 7 7 85024 Automated hemogram 5 8 25 18 21 5 14 24 21 5 84153 Assay of PSA,totala 18 35 61 21 27 36 31 27 24 23 80092 Thyroid panel w/TSHb 10 22 72 22 20 35 27 49 54 10 85610 Prothrombin time 6 20 17 15 15 16 18 15 12 6 83036 Glycated hemoglobin test 20 32 16 19 21 25 21 20 11 6 80049 Metabolic panel, basic 4 9 7 4 6 14 4 8 4 5 81000 Urinalysis, nonauto w/scope 6 8 9 7 10 18 9 7 4 6 87086 Urine culture/colony count 9 8 15 15 17 19 24 14 20 6 83970 Assay of parathormone 25 11 13 5 7 4 5 13 5 7 88342 Immunocytochemistry 5 28 12 4 3 1 5 5 4 12 80162 Assay of digoxin 15 9 34 23 24 38 31 17 19 4 82607 Vitamin B-12 4 12 9 9 8 38 5 20 39 5 82728 Assay of ferritin 26 45 30 30 33 47 34 59 21 6 82947 Assay of glucose, quant 15 19 30 22 33 41 39 34 9 23 83718 Assay of lipoprotein 21 28 46 24 19 42 30 36 19 15 80058 Hepatic function panel 3 8 8 5 7 9 4 9 4 7 G0001 Venipuncture 10 8 8 7 15 11 6 11 7 6 80061 Lipid panel 26 18 18 19 14 9 24 41 14 21

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Medicare Laboratory Payment Policy: Now and in the Future     Denial Rate (percentage)     2050 5130 5440 5535 10071 10230 10240 10250 10490 11260 CPT Code Description CA(T) ID TN NC RR CT MN MS VA MO 85025 Automated hemogram 29 6 61 35 15 9 13 26 6 33 84443 Assay TSH 15 28 34 24 15 13 13 23 14 23 80054 Comp metabol panel 9 7 11 16 15 8 4 8 4 10 85024 Automated hemogram 19 8 32 31 16 9 40 26 7 22 84153 Assay of PSA, totala 25 40 32 44 15 7 52 34 18 46 80092 Thyroid panel w/TSHa 20 30 33 27 15 10 11   9 25 85610 Prothrombin time 7 14 14 12 15 7 7 17 8 13 83036 Glycated hemoglobin test 19 23 19 15 15 10 11 7 14 23 80049 Metabolic panel, basic 9 8 8 10 15 12 4 6 3 9 81000 Urinalysis, nonauto w/scope 15 7 11 17 16 13 18 21 13 7 87086 Urine culture/colony count 14 23 20 16 15 7 11 4 8 19 83970 Assay of parathormone 8 3 8 9 12 13 5 12 8 5 88342 Immunocytochemistry 14 8 12 11 24 14 16 12 11 27 80162 Assay of digoxin 9 13 20 27 15 8 12 16 7 16 82607 Vitamin B-12 11 5 11 38 16 11 3 12 7 5 82728 Assay of ferritin 31 42 16 38 13 44 10 20 8 30 82947 Assay of glucose, quant 20 38 29 30 19 13 4 24 18 41 83718 Assay of lipoprotein 16 30 28 20 19 14 21 22 9 25 80058 Hepatic function panel 11 5 9 9 14 10 4 6 4 53

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Medicare Laboratory Payment Policy: Now and in the Future     Denial Rate (percentage)     14330 16360 16510 31140 31142 31143 31144 31145 CPT Code Description NY(G) OH WV CA(N) ME MA NH VT G0001 Venipuncture 8 6 5 9 4 5 6 5 80061 Lipid panel 15 18 12 37 9 9 12 15 85025 Automated hemogram 24 7 6 12 9 7 11 10 84443 Assay TSH 16 24 16 47 16 15 19 22 80054 Comp metabol panel 7 7 5 14 6 5 10 4 85024 Automated hemogram 20 4 3 6 7 10 10 7 84153 Assay of PSA, totala 29 24 19 38 27 28 32 38 80092 Thyroid panel w/TSHb 16 40 37 44 14 10 16 11 85610 Prothrombin time 14 13 12 6 10 7 10 9 83036 Glycated hemoglobin test 14 15 10 10 14 11 16 22 80049 Metabolic panel, basic 4 5 4 8 3 4 5 5 81000 Urinalysis, nonauto w/scope 24 7 3 11 5 9 6 7 87086 Urine culture/colony count 16 14 8 6 17 11 18 16 83970 Assay of parathormone 8 15 4 3 10 5 7 NA 88342 Immunocytochemistry 12 4 3 10 5 11 4 2 80162 Assay of digoxin 17 24 22 7 21 15 19 25 82607 Vitamin B-12 13 7 6 1 8 6 10 4 82728 Assay of ferritin 41 33 27 5 29 19 22 30 82947 Assay of glucose, quant 44 22 15 15 19 25 28 19 83718 Assay of lipoprotein 14 27 20 56 16 21 21 19 80058 Hepatic function panel 6 5 4 69 5 4 7 5

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Medicare Laboratory Payment Policy: Now and in the Future NOTE: The committee was unable to obtain an explanation for the denials. Since many of the tests with high denial rates are not screening tests, this does not fully explain the high denial rates. Other possible reasons for claims denials include stringent local medical review policies, contractors’ inability to match ICD-9 codes with the appropriate CPT codes due to flaws in their computer programs, duplicative bills for a claim that was already paid, the patient is not eligible for benefits, the provider is not an approved Medicare provider, or the provider is billing for a type of test that is outside the laboratory’s CLIA certification level. There appears to be no obvious pattern to the denial rates. One test that has a high rate of denial in one carrier region will have a very low denial rate in another carrier region. LMRP = local medical review policy; PSA = prostate specific antigen; TSH = thyroid-stimulating hormone. aCoverage was recently extended to screening, once per year. bPanel was eliminated in 2000 but there will still be LMRP for each individual test.