Lipid panel
Audit Defense & Denial Intelligence
Research-based denial patterns from OrbDoc Bill Analyzer
1. Lipid panel frequency limit exceeded - screening interval not met
Very Common80061 (lipid panel: cholesterol, HDL, LDL, triglycerides) has strict frequency limits. Medicare/commercial payers allow screening lipids every 5 years for low-risk patients, every 1 year for patients on lipid-lowering therapy or at-risk, every 6 months for therapy adjustment. Denied when screening performed more frequently without documented indication.
Common Causes
- • Annual physical lipid panel when prior panel <12 months and patient not on statin - 5-year screening interval for low-risk
- • Repeat lipids 3 months after starting statin - 6-12 week interval appropriate, 3 months too soon
- • Multiple lipid panels same year without therapy change - once yearly adequate for stable patients
Resolution Strategy
Document appropriate indication: 'Patient with known hyperlipidemia on atorvastatin 40mg daily, started 10 weeks ago. Baseline lipids: Total cholesterol 280, LDL 195, HDL 38, triglycerides 235. Repeat lipid panel at 12 weeks to assess response to therapy and determine if statin dose adjustment needed per ACC/AHA guidelines.' Must specify: baseline lipids and date, therapy initiated, appropriate interval (6-12 weeks for therapy adjustment, 1 year for stable monitoring), how results change management. For screening without risk factors, 5-year interval. Cannot appeal more frequent testing without clinical indication or therapy change.
💬 Plain Language Explanation
What this means
This is a lipid panel - a blood test that checks your cholesterol and triglyceride levels.
Why you might see this
This is a common lab test for checking heart health. Your doctor likely ordered this to check your cholesterol levels, which is often done during routine check-ups or to monitor heart disease risk.
Common context
Common routine lab test for heart health screening, often part of annual physicals.
What to ask your provider
"'What were my cholesterol levels? Are they within normal ranges?'"
Relative Value Units (RVUs)
Calculator →
Clinical Information
When to Use
Lipid panel including total cholesterol, HDL cholesterol, LDL cholesterol (direct or calculated), and triglycerides
Common Scenarios
Documentation Requirements
- Order from physician required
- Test results documented
- Normal/abnormal values reported
- Clinical interpretation if applicable
Coding Guidelines
Common Modifiers
Bundling Rules
- Panel includes lipid profile tests
- Cannot bill individual component tests separately
- Includes total cholesterol, HDL, LDL, and triglycerides
Exclusions
- Do not bill individual lipid codes if panel billed
- Do not bill component tests on same day
Coding Notes
Clinical scenarios
- Order from physician required
- Test results documented
- Normal/abnormal values reported
- Order from physician required
- Test results documented
- Normal/abnormal values reported
- Order from physician required
- Test results documented
- Normal/abnormal values reported
Who are you?
Code Details
Medicare Pricing
PFSRVU Breakdown
OPPS Details
National Limit: $13.39
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Ask a QuestionFrequently Asked Questions
CPT 80061 is the billing code for "Lipid panel". Lipid panel including total cholesterol, HDL cholesterol, LDL cholesterol (direct or calculated), and triglycerides
CPT 80061 has a total RVU of 0.81, broken down as: Work RVU 0.05, Practice Expense RVU 0.75, and Malpractice RVU 0.01. RVUs (Relative Value Units) determine Medicare reimbursement rates.
The most common denial reason for CPT 80061 is "Lipid panel frequency limit exceeded - screening interval not met". 80061 (lipid panel: cholesterol, HDL, LDL, triglycerides) has strict frequency limits. Medicare/commercial payers allow screening lipids every 5 years for low-risk patients, every 1 year for patients on lipid-lowering therapy or at-risk, every 6 months for therapy adjustment. Denied when screening performed more frequently without documented indication. Common causes include: Annual physical lipid panel when prior panel <12 months and patient not on statin - 5-year screening interval for low-risk; Repeat lipids 3 months after starting statin - 6-12 week interval appropriate, 3 months too soon. Appeal success rate is approximately 10-30%.
Key documentation requirements for CPT 80061 include: Order from physician required; Test results documented; Normal/abnormal values reported; Clinical interpretation if applicable. Missing or incomplete documentation is a leading cause of claim denials for this code.
Bundling considerations for CPT 80061: Panel includes lipid profile tests. Cannot bill individual component tests separately Use an NCCI bundling checker to verify specific code combinations before billing.
Common modifiers for CPT 80061 include: 26 (Professional component only (interpretation)), TC (Technical component only (performance)). Modifiers indicate special circumstances and can affect reimbursement or prevent claim denials.
The typical time requirement for CPT 80061 is Automated testing - results typically available within hours. Time-based codes require documentation of the actual time spent providing the service.