Coding for Coverage for Lipid Testing

The APA HelpLine has recently received a number of calls from APA members who are concerned about Medicare’s failure to pay for the regular lipid tests that are essential for their patients who are taking second-generation antipsychotics (SGAs). If you want your patients on SGAs to be reimbursed for their lipid testing, we suggest that you use diagnosis code V58.69 on your referral for the test.

In 2004 APA participated in a consensus-development conference on antipsychotic medications and obesity and diabetes with the American Diabetes Association, the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity. The result of this conference was a consensus statement that calls for, among other types of monitoring, lipid profiles for patients prescribed SGAs. A baseline fasting lipid profile is to be taken before beginning the drug regimen, followed by another at 12 weeks, and, if all is normal at that point and the medication continued, another lipid profile every five years that the patient is taking the medication.

In the past, Medicare contractors routinely covered lipid testing ordered by psychiatrists, regardless of whether they provided a diagnosis of bipolar disorder or psychosis or used the code 995.20, listed in DSM-5 for “unspecified adverse effect of unspecified drug, medicinal, and biological substance.”

In October 2014, however, the Centers for Medicare and Medicaid Services (CMS) issued a National Coverage Determination (NCD) on Lipids Testing (NCD 190.23) that provided four pages of diagnostic codes for which lipid testing is covered by Medicare—no other codes are permitted. Although no psychiatric diagnoses appear on the list, it does include a code that is appropriate for psychiatrists to use for their patients on SGAs, V58.69. This code is defined as being for “long-term (current) use of other medications” and covers unspecified high-risk medications.

The argument in favor of using this code rather than the code for your patient’s psychiatric diagnosis is that the test is not related to the patient’s disorder, but rather to the use of a medication that puts the patient at risk for developing medical problems that the lipid testing can help prevent.

One confusion that has arisen is that the NCD fails to include the code provided in DSM-5, which would seem to cover the same issue. APA approached senior staff at CMS about amending the NCD to include code 995.20, but the response was that APA should educate its members to use the appropriate code from the list currently included in the NCD. We will continue to engage with CMS about the addition of the code listed in DSM-5, but until then, here’s the final word: If you wish your patients on SGAs to be reimbursed for their lipid testing, use diagnosis code V58.69 on your referral for the test. ■