Here are some claim editing reminders

CPT Category II codes: The lab codes below require a CPT Category II code when you’re providing test results and the test was performed in an office location. CPT Category II codes are a set of tracking codes that can be used to measure performance. They may be used to describe results from clinical laboratory or radiology tests and other procedures intended to address patient safety issues.

*80061 — Lipid panel. This panel must include the following:

• Cholesterol, serum, total (*82465)
• Lipoprotein, direct measurement; HDL cholesterol (*83718)
• Triglycerides (*84478)

*83036 — Hemoglobin; glycosylated (A1c)
*83721— Lipoprotein, direct measurement; LDL cholesterol

Claims that are submitted without the associated CPT Category II code may undergo claim editing and be denied. If you receive a claim denial, submit a corrected claim with the appropriate Category II code, not an appeal.

New patient visit edits: A new patient is one who hasn’t received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. Prior visits are those indicated with evaluation and management codes or other face-to-face professional services billed within a three-year period. A face-to-face professional service includes E&M codes, surgical procedures and other procedures or services. Only one new patient visit is allowed in a three-year period.

New patient claims that are submitted within three years of a prior new patient visit or any face-to-face service may be denied. If you receive a claim denial, submit a corrected claim using the appropriate established patient E&M code, not an appeal.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.