CPT 80053 presents a comprehensive analysis of metabolic components of human physiology. The human body consists of many complex systems.
These systems are responsible for maintaining our body in the normal physiological state to perform our routine activities by working together.
However, due to various reasons, the balance of these metabolic components could be altered, directly impacting the quality of life.
CPT 80053 includes the analysis of below metabolic components, for example;
- total Calcium;
- total Carbon dioxide (bicarbonate);
- Glucose Phosphatase;
- alkaline Potassium Protein;
- total Sodium;
- alanine amino (ALT) (SGPT) Transferase;
- spartate amino (AST) (SGOT); and
- Urea nitrogen (BUN).
CPT 80053 Description
In the pathology or Lab section, to perform a Comprehensive metabolic or chemical panel, the physician or other qualified healthcare professional, e.g., registered nurse or physician assistant, performs venipuncture to collect a blood sample. A separate set of CPT codes is available to reimburse the venipuncture procedure as this is not considered an inherent part of the main service CPT 80053.
The 80053 CPT code (comprehensive metabolic panel) can be broadly classified into five different sub-sections based on the physiological studies of the organ system as follows. These tests are inherently included in CPT 80053 as per the description released by the American Medical Association (AMA).
The first sub-category is the ‘kidney function studies’ in which blood urea nitrogen (CPT 84520) and creatinine (CPT 82565) tests are performed. It is also represented as RFTs (Renal Function Test).
Both (blood urea nitrogen (BUN) and creatinine (Cr)) are the by-products of metabolic activities and are excreted through the urinary system; thus, the physician reviews the test results to identify any potential issues of the urinary system.
The second sub-category is the ‘serum electrolyte study’ which includes Sodium in whole plasma (CPT 84295), potassium in whole plasma (CPT 84132), chloride (CPT 82435), and Carbon dioxide (CPT 82374) studies. Balance of these electrolytes in plasma plays a vital role in keeping all the body’s organic functions in balance.
The third sub-category includes the general tests, specifically blood glucose (CPT 82947) and Calcium (CPT 82310). Both of these tests represent the quantities of Calcium and glucose in whole plasma. All trace elements play a vital role in the human body as they keep our regular aerobic and anaerobic cycles in balance.
The fourth sub-category involves protein tests in which the physician can analyze the liver and kidney health status. These tests are total serum protein (CPT 84155) and total plasma albumin (CPT 82040). Both liver and kidneys are responsible for maintaining these proteins’ levels in blood plasma. These proteins play a vital role in maintaining normal functions.
The fifth sub-category includes the tests for assessment of liver function. It provides the values for the most important components, namely;
- Bilirubin (CPT 82247);
- ALP alkaline phosphatase (CPT 84075);
- AST aspartate aminotransferase (CPT 84450); and
- ALT alanine aminotransferase (CPT 84460).
It is also denoted as LFTs (Liver Function Test).
These sub-categories are represented by a single code, CPT 80053, as a comprehensive metabolic panel. But, as per AMA (American Medical Association) coding guidelines, if only a single test from the above-cited panel is not performed, the biller or coder should not use CPT 80053.
So, again, as per AMA, in this case, the biller or coder may have to present each service separately.
Conditions For CPT 80053
A comprehensive metabolic panel (CPT code 80053) is a lab test ordered by a physician either for a screening purpose or for patients with metabolic disorders, such as diabetes, hypertensive heart with renal disease, severe metabolic acidosis, or sepsis.
This panel includes 14 baseline tests of all vital organs most affected in case of any acute or chronic disorder. The primary purpose is the adequate monitoring of these vital organs so that a suitable measure should be taken if any anomaly in the body is detected.
In screenings, it is expected that physicians order this test as part of a routine checkup. This test is obligatory for a routine checkup so that any underlying health disorder can be identified and addressed before it begins to show any symptoms.
For some patients who take certain medications for a prolonged duration, the physician can order a comprehensive metabolic panel (the 80053 CPT code) to view the patient’s health status overall because the prolonged use of medications does have serious adverse effects on normal systemic metabolism.
The most common example of prolonged usage of drugs is ‘Diabetes mellitus Type 1’ or ‘Diabetes Mellitus Type 2’. In both cases, the patient has to take insulin or other antidiabetic medications for the whole life to maintain optimal glucose levels in the blood.
Hence, a patient with diabetes, either ‘Type 1’ or ‘Type 2’, must order routinely for a comprehensive metabolic panel exam (CPT 80053) to monitor the health of all vital organs. And if it is required, any dose adjustments can be made accordingly by the physician.
The comprehensive metabolic panel test (CPT 80053) is sensitive. The values can vary if proper precautions are not taken. Appropriate rest and at least 10 – 12 hours of fasting are prerequisites for this test as food, and physical activity can alter the final test results.
Billing Guidelines And Reimbursement Policy For CPT 80053
Individual payers govern the reimbursement policy of CPT 80053. Almost all insurances, e.g., Government insurances (Medicaid or Medicare) and Commercial insurances, recognize and pay for this exam without any special requirements.
The coder or biller should pay proper attention during CPT selection for this service because there is a very close resemblance between the 80053 CPT code (comprehensive metabolic panel) and 80048 (Basic metabolic panel).
CPT 80053 and CPT 80048 have different RVUs (Relative Value Unit) and have overall other inclusive services.
So, the selection of CPT codes is crucial because it may negatively impact the overall revenue cycle of ongoing practice.
As per CMS manual coding instructions, it is not allowed to bill CPT code 80053 and CPT 80048 at the exact date of service (DOS) in a single claim.
Because both of these services (CPTs) are mutually exclusive, there is no such modifier announced or available to override the ‘edit’ between these two services (CPTs).
Suppose there is a situation where MEE (Mutually Exclusive Edit) exists between two services performed on the same date of service (DOS). Then, the coder or biller should bill only the service to the payer with the higher RVUs (Relative Value Unit).
Suppose both services (CPT 80053 and CPT 80048) are billed together in a single claim, despite knowing the MEE (Mutually Exclusive Edit) edit. In that case, the payer (insurance company) may process the claim by paying for the only service having lower SUVs (Standardized Uptake Value) based on the medical necessity.
This may hugely influence the reimbursement, which may decrease the considerable amount of overall revenue of the whole practice.
The MUE (Mutually Unlikely Edit) adjudication indicator for the 80053 code is three into one. This means when necessity is met, the coder or biller can bill it more than once a day (same DOS) provided with appropriate medical documentation.
For example, a physician may order this service twice at a different time on the same day during the patient’s stay for monitoring purposes or for an overall picture for comparing values after starting the medication therapy.
CPT code 80053 was first released and recognised by CMS (Centers for Medicare and Medicaid Services) manual on 01/01/2000. AMA (American Medical Association) announced the last update of the 80053 CPT code on 01/01/2009.
It is not an appropriate method to report each component of CPT 80053 individually. Since the CMS manual always recommends using panel codes when tests of each of the components are performed (if the components are included in panel CPT codes).
Insurances may deny the claim when each test is reported separately as an individual line item. This mode of billing the services can also provoke audits by the insurance companies that may result in penalties.
Does CPT 80053 Needs A Modifier?
Modifiers are necessary to present particular circumstances and to get appropriate reimbursements. Therefore, in the pathology section of the CPT coding manual, it is imperative to know the proper use of scenario-specific modifiers.
Modifier 59 is required to be appended with column 2 to override Comprehensive Component Edit (CCE). CMS has announced a set of modifiers for this edit, such as modifier XS, modifier SP, and modifier SU. But in the pathology section, modifier 59 is the most preferred one.
When the service is performed by a third party, i.e., outside a laboratory, then modifier 90 should be appended with the pathology section CPT. Only the provider or outside lab should bill the service (CPT). Although the actual service is provided in a definite way, it can cause duplication of the claim, and both parties may not get any reimbursements.
Suppose there is an agreement between the physician’s office and outside lab in such a scenario that the physician’s office is responsible for paying the lab.
In that case, the CPT should be billed by the physician’s office with modifier 90 at the primary position in the claim. If there is no such agreement, only the laboratory can bill the service to get the reimbursements.
The laboratory should bill the CPT with modifier 90 to get the payments from insurance. Only a single party should be billing the claim to avoid any duplications.
Modifier 90 is not applicable with CPT 36415 as this CPT represents the venipuncture to collect the blood sample.
It is necessary to repeat any pathology section test on the same day (same DOS) on the same patient in a few scenarios. With the help of modifier 91, this can be achieved
Modifier 91 should be appended with the CPT code 80053 or any other pathology section CPT to present the repetition of the service on the same day (same DOS). Otherwise, insurance companies may consider it a duplicate service, which may get denied.
Although a separate usual procedure number is submitted in the claim, modifier 91 is necessary to get the claim paid by the government and commercial payers.
If the test is performed inside the physician’s office, it should be billed with modifier QW to present that it is a CLIA (Clinical Laboratory Improvement Amendments) waived test.
CLIA certification is issued by US health and human services to qualified entities. Each individual who is CLIA certified entity is assigned a CLIA certification number and should be submitted for each pathology section claim along with the modifier QW.
A patient with diabetes and cardiorenal syndrome came to the physician’s office for a routine checkup on his health status and review of medications.
In addition, the physician performed a physical exam and ordered a comprehensive metabolic panel to evaluate the patient’s physiological condition.
In the above example, the provider’s office withdraws a blood sample using the venipuncture technique presented in the claim by CPT 36415 and CPT 80053 (for a comprehensive metabolic panel exam).
Now, if the physician’s office is CLIA certified, a coder or biller must submit modifier QW with CPT 80053.
Another scenario will be if a referenced, outside laboratory performs the test, depending on the physician’s agreement with the lab.
If the physician pays the lab, the physician can bill it with modifier 91 to reimburse the service.
If there is no such agreement with the outside lab, the outside lab can bill the service with modifier 91.