Medical Policy Bulletin

Section:	Laboratory
Number:	L-27
Topic:	Organ or Disease Oriented Panels
Effective Date:	August 1, 2005
Issued Date:	September 10, 2007
Date Last Reviewed:	08/2005

General Policy Guidelines

Indications and Limitations of Coverage

Procedure codes 80048-80090 represent organ or disease oriented panels. These panels combine certain laboratory tests under a specific problem-oriented classification. When performed for asymptomatic patients, organ or disease oriented panels are considered screening and are only covered by certain groups or programs as indicated in benefits. A participating, preferred, or network provider may bill the member for the denied panel.

Many of the disease-oriented panel tests on the Table Attachment below are covered. The component tests for each covered panel are listed. These are the minimum tests that must be performed before a disease-oriented panel code can be reported.

If less than the minimum tests are performed, payment should be made for the individual tests.

Coverage for routine screening tests is determined according to individual or group customer benefits.

See Medical Policy Bulletin L-29 for information regarding evocative/suppression testing panels.

Procedure Codes

80048	80050	80051	80053	80055	80061
80069	80074	80076

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

View Previous Versions

[Version 001 of L-27]

Table Attachment

ORGAN OR DISEASE ORIENTED PANELS

Procedure Code	Action
80050 General health panel	Define components as: 80053 - Comprehensive metabolic panel 85025 or 85027 and 85004 - Blood count, complete (CBC), automated and automated differential WBC count OR 85027 and (85007 or 85009) - Blood count, complete (CBC), automated appropriate manual differential WBC 84443 - Thyroid stimulating hormone (TSH)
80048 Basic metabolic panel	Define components as: 82310 - Calcium 82374 - Carbon dioxide 82435 - Chloride 82565 - Creatinine 82947 - Glucose 84132 - Potassium 84295 - Sodium 84520 - Urea Nitrogen (BUN)
80051 Electrolyte panel	Define components as: 82374 - Carbon dioxide 82435 - Chloride 84132 - Potassium 84295 - Sodium
80053 Comprehensive metabolic panel	82040 - Albumin 82247 - Bilirubin, total 82310 - Calcium 82374 - Carbon Dioxide (bicarbonate) 82435 - Chloride 82565 - Creatinine 82947 - Glucose 84075 - Phosphatase, alkaline 84132 - Potassium 84155 - Protein, total 84295 - Sodium 84450 - Transferase, aspartate amino (AST) (SGOT) 84460 - Transferase, alanine amino (ALT)(SGPT) 84520 - Urea nitrogen (BUN)
80055 Obstetric panel	85025 or 85027 and 85004 - Blood count, complete (CBC), automated and automated differential WBC count OR 85027 and (85007 or 85009) - Blood count, complete (CBC), automated appropriate manual differential WBC 87340 - Hepatitis B surface antigen (HBsAg) 86762 - Antibody, rubella 86592 - Syphilis test, qualitative (e.g., VDRL, RPR, ART) 86850 - Antibody screen, RBC, each serum technique 86900 - Blood typing, ABO 86901 - Blood typing, Rh(D)
80061 Lipid panel	Define components as: 82465 - Cholesterol, serum; total 83718 - Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) 84478 - Triglycerides, blood
80069 Renal function panel	Define components as: 82040 - Albumin 82310 - Calcium 82374 - Carbon Dioxide (bicarbonate) 82435 - Chloride 82565 - Creatinine 82947 - Glucose 84100 - Phosphorus inorganic (phosphate) 84132 - Potassium 84295 - Sodium 84520 - Urea nitrogen (BUN)
80074 Hepatitis panel	Define components as: 87340 - Hepatitis B surface antigen (HBsAg) 86705 - Hepatitis B core antibody (HbcAb), IgM antibody 86709 - Hepatitis A antibody (HAAb),IgM antibody 86803 - Hepatitis C antibody
80076 Hepatic function panel	Define components as: 82040 - Albumin 82247 - Bilirubin, total 82448 - Bilirubin, direct 84075 - Phosphatase, alkaline 84155 - Protein, total 84450 - Transferase, aspartate amino (AST) (SGOT) 84460 - Transferase, alanine amino (ALT) (SGPT)

Text Attachment

Procedure Code Attachment

Glossary

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.