Read "Medicare Laboratory Payment Policy: Now and in the Future" at NAP.edu

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Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

APPENDIX E
1998 Medicare Carrier Denial Rates

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Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

TABLE E.1 1998 Medicare Carrier Denial Rates for Top 100 CPT Codes

Obs. No.	CPT	Description	Total Claims	Allowed Services	Denied Claims	Percent Denied
1	G0001	Venipuncture	54,308,311	50,522,357	3,785,954	7
2	80061	Lipid panel	10,012,394	8,112,908	1,899,486	19
3	85025	Automated hemogram	13,484,091	10,641,281	2,842,810	21
4	84443	Assay TSH	5,871,658	4,579,775	1,291,883	22
5	80054	Comp metabolic panel	10,290,202	9,491,333	798,869	8
6	85024	Automated hemogram	8,662,269	7,358,832	1,303,437	15
7	84153	Assay of PSA, total	4,756,531	3,284,409	1,472,122	31
8	80092	Thyroid panel w/TSH	2,534,185	1,974,563	559,622	22
9	85610	Prothombin time	14,291,139	12,574,088	1,717,051	12
10	83036	Glycated hemoglobin test	5,066,357	4,162,652	903,705	18
11	80049	Metabolic panel, basic	5,828,554	5,468,084	360,470	6
12	81000	Urinalysis, nonauto w/scope	10,333,195	9,197,005	1,136,190	11
13	87086	Urine culture/colony count	3,470,828	2,977,871	492,957	14
14	83970	Assay of parathormone	607,387	563,481	43,906	7
15	88342	Immunocytochemistry	773,537	679,395	94,142	12
16	80162	Assay of digoxin	2,217,224	1,719,286	497,938	22
17	82607	Vitamin B-12	1,293,984	1,148,163	145,821	11
18	82728	Assay of ferritin	1,676,425	1,206,352	470,073	28
19	82947	Assay of glucose, quant	6,808,196	5,095,476	1,712,720	25
20	83718	Assay of lipoprotein	2,735,590	1,971,582	764,008	28
21	80058	Hepatic function panel	3,257,316	2,793,817	463,499	14
22	83550	Iron-binding test	2,222,641	1,672,426	550,215	25
23	83540	Assay of iron	3,125,180	2,065,183	1,059,997	34
24	85023	Automated hemogram	1,679,112	1,482,497	196,615	12
25	87186	Antibiotic sensitivity, mic	1,541,216	1,423,826	117,380	8
26	88312	Special stains	750,231	691,029	59,202	8
27	82746	Blood folic acid serum	912,478	791,881	120,597	13
28	80185	Assay of phenytoin, total	839,618	778,174	61,444	7

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Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

29	87340	Hep B surface antigen, EIA	1,066,065	990,005	76,060	7
30	82378	Carcinoembryonic antigen	717,046	523,034	194,012	27
31	88180	Cell marker study	765,834	578,032	187,802	25
32	87088	Urine bacteria culture	1,421,349	1,208,672	212,677	15
33	81001	Urinalysis, auto w/scope	3,123,900	2,832,521	291,379	9
34	82108	Assay of aluminum	374,227	347,575	26,652	7
35	83721	Assay of blood lipoprotein	1,016,926	890,414	126,512	12
36	85651	RBC sed rate, nonautomated	2,852,933	2,382,302	470,631	16
37	84439	Assay of free thyroxine	1,043,574	875,160	168,414	16
38	81002	Urinalysis nonauto w/o scope	3,672,390	3,040,808	631,582	17
39	84132	Assay of serum potassium	3,228,326	2,903,922	324,404	10
40	85027	Automated hemogram	1,347,928	1,117,113	230,815	17
41	80051	Electrolyte panel	1,686,997	1,564,619	122,378	7
42	84460	Alanine (alt) (SGPT)	4,473,439	4,022,030	451,409	10
43	82565	Assay of creatine	3,690,794	3,361,129	329,665	9
44	83735	Assay of magnesium	1,658,816	1,051,152	607,664	37
45	84436	Assay of total thyroxine	1,328,819	967,532	361,287	27
46	87070	Culture specimen, bacteria	795,903	732,725	63,178	8
47	88313	Special stains	714,671	644,559	70,112	10
48	82270	Test for blood, feces	3,582,984	2,406,732	1,176,252	33
49	84480	Assay, triiodothyronine (t³)	478,533	427,966	50,567	11
50	86038	Antinuclear, antibodies	490,385	449,731	40,654	8
51	86235	Nuclear antigen antibodies	355,112	310,794	44,318	12
52	80059	Hepatitis panel	111,194	89,049	22,145	20
53	84165	Assay of serum proteins	478,051	441,159	36,892	8
54	82962	Glucose blood test	2,025,904	1,624,456	401,448	20
55	83615	Lactate (LD) (LDH) enzyme	3,590,958	3,229,463	361,495	10
56	82465	Assay of serum cholesterol	3,796,842	2,545,361	1,251,481	33
57	84550	Assay of blood uric acid	3,631,496	3,269,558	361,938	10
58	80164	Assay, dipropylaoctic acid	384,222	358,712	25,510	7
59	86316	Immunoassay, tumor antigen	380,049	230,267	149,782	39

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Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

Obs. No.	CPT	Description	Total Claims	Allowed Services	Denied Claims	Percent Denied
60	84520	Assay of urea nitrogen	3,142,103	2,829,708	312,395	10
61	84134	Assay of prealbumin	369,369	337,573	31,796	9
62	80091	Thyroid panel	494,986	341,512	153,474	31
63	87184	Antibiotic sensitivity, each	710,761	662,935	47,826	7
64	84466	Assay of transferrin	412,205	368,777	43,428	11
65	85021	Automated hemogram	945,869	785,785	160,084	17
66	88311	Decalcify tissues	521,382	476,714	44,668	9
67	84450	Transfarase (AST) (SGOT)	2,472,065	2,207,233	264,832	11
68	84403	Assay of total testosterone	182,640	166,282	16,358	9
69	80198	Assay of theophylline	316,372	296,049	20,323	6
70	85730	Thromboplastin time, partial	1,011,362	672,243	339,119	34
71	84100	Assay of phosphrus	3,277,539	2,945,742	331,797	10
72	88358	Analysis, tumor	45,022	33,684	11,338	25
73	82784	Assay of gammaglobulin IGM	475,411	443,826	31,585	7
74	80156	Assay of carbamazepine	290,031	270,482	19,549	7
75	87536	HIV-1 DNA, guant	61,753	50,847	10,906	18
76	88156	Cytopath cerv/vag tbs	1,123,563	705,034	418,529	37
77	p3000	Screen Pap by tech w md spuv		696,620
78	86677	Helicobacter pylori	294,970	261,064	33,906	11
79	87163	Special microbiology culture	365,712	332,893	32,819	9
80	85022	Automated hemogram	721,987	625,796	96,191	13
81	86706	Hepatitis B surface antibody	318,970	291,801	27,169	9
82	82977	Assay of GGT	2,710,498	1,776,256	934,242	34
83	82985	Glycated protein	267,351	207,433	59,918	22
84	82310	Assay of calcium	1,835,714	1,627,676	208,038	11
85	84478	Assay of triglycerides	2,325,893	1,547,433	778,460	33
86	82150	Assay of amylase	522,595	457,640	64,955	12
87	81003	Urinalysis, auto w/o scope	1,524,186	1,304,784	219,402	14

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Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

88	80100	Drug screen	236,133	206,622	29,511	12
89	86803	Hepatitis c ab test	221,837	198,565	23,272	10
90	80101	Drug screen	281,363	242,105	39,258	14
91	82131	Amino acids, single quant	200,511	166,743	33,768	17
92	85045	Reticulocyte count	718,565	643,016	75,549	11
93	82550	Assay of CK (CPK)	992,983	888,071	104,912	11
94	88346	Immunofluorescent study	100,003	87,556	12,447	12
95	86003	Allergen specific ige	642,755	537,312	105,443	16
96	G0107	CA screen fecal blood test		909,427
97	84295	Assay of serum sodium	1,605,560	1,449,005	156,555	10
98	86334	Immunofixation procedure	112,513	103,770	8,743	8
99	85007	Differential WBC Count	677,050	590,005	87,045	13
100	80158	Assay of cyclosporine	122,397	109,266	13,131	11
		AVERAGE	266,287,495	228,699,563	39,193,969	15
NOTE: The committee was unable to obtain an explanation for the denials. Since many of the tests with high denial rates are not screening tests, this does not fully explain the high denial rates. Other possible reasons for claims denials include stringent local medical review policies, contractors’ inability to match ICD-9 codes with the appropriate CPT codes due to flaws in their computer programs, duplicative bills for a claim that was already paid, the patient is not eligible for benefits, the provider is not an approved Medicare provider, or the provider is billing for a type of test that is outside the laboratory’s CLIA certification level. There appears to be no obvious pattern to the denial rates. One test that has a high rate of denial in one carrier region will have a very low denial rate in another carrier region. AST = aspartate transominase; CK = creatine kinase; CPK = creatine phosphokinase; CPT = Current Procedural Terminology; EIA = enzyme immunoassay; GGT = γ-glutamyl transferase; MIC = minimum inhibitory concentration; PSA = prostate-specific antigen; RBC = red-blood cell; SGOT = serum glutamic-oxalvacetic transaminase; SGPT = serum glutamic-pyruvic transaminase; TSH = thyroid-stimulating hormone; WBC = white-blood cell.

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Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

TABLE E.2 1998 Medicare Carrier Denial Rates for the Top 20 Clinical Laboratory Tests, by State

		Denial Rate (percentage)
		510	511	520	521	522	528	590	621	623
CPT Code	Description	AL	GA	AR	NM	OK	LA	FL	IL	MI
G0001	Venipuncture	5	7	5	8	6	7	7	7	5
80061	Lipid panel	14	17	5	25	14	16	15	23	17
85025	Automated hemogram	27	35	5	29	5	17	14	34	35
84443	Assay TSH	19	26	23	30	17	30	26	8	7
80054	Comp metabol panel	6	8	5	6	4	6	6	9	6
85024	Automated hemogram	18	16	4	6	8	13	12	19	19
84153	Assay of PSA, total^a	41	33	53	32	11	50	41	29	30
80092	Thyroid panel w/TSH^b	25	8	30	20	14	27	21	22	8
85610	Prothrombin time	9	12	4	14	12	12	13	15	15
83036	Glycated hemoglobin test	14	20	13	20	14	19	17	17	18
80049	Metabolic panel, basic	4	6	4	5	3	4	5	7	4
81000	Urinalysis, nonauto w/scope	20	16	13	7	12	5	8	9	6
87086	Urine culture/colony count	12	18	6	7	3	18	15	23	19
83970	Assay of parathormone	4	28	3	8	4	9	5	5	6
88342	Immunocytochemistry	21	6	12	33	25	12	10	31	21
80162	Assay of digoxin	30	49	26	17	12	22	24	47	53
82607	Vitamin B-12	5	6	6	6	3	8	6	9	6
82728	Assay of ferritin	32	33	53	38	17	55	9	15	17
82947	Assay of glucose, quant	25	27	21	14	8	19	29	26	39
83718	Assay of lipoprotein	19	27	7	45	29	37	34	40	41
80058	Hepatic function panel	48	46	6	5	4	47	5	7	4

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Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

		Denial Rate (percentage)
		630	640	650	655	660	740	751	801	803
CPT Code	Description	IN	IA	KS	NE	KY	MO	MT	NY(W)	NY(E)
G0001	Venipuncture	7	4	2	3	5	4	32	7	12
80061	Lipid panel	15	9	23	25	15	34	19	7	20
85025	Automated hemogram	7	5	5	9	31	5	65	12	33
84443	Assay TSH	38	16	9	11	21	15	39	24	33
80054	Comp metabol panel	7	10	3	6	10	5	16	6	11
85024	Automated hemogram	9	7	3	6	14	4	29	6	27
84153	Assay of PSA, total^a	54	46	30	30	26	36	41	46	46
80092	Thyroid panel w/TSH^b	39	15	12	10	23	15	34	20	26
85610	Prothrombin time	16	2	7	6	43	9	34	12	21
83036	Glycated hemoglobin test	17	3	8	9	5	12	41	19	39
80049	Metabolic panel, basic	6	5	3	3	7	3	24	4	10
81000	Urinalysis, nonauto w/scope	6	13	4	5	12	7	38	14	22
87086	Urine culture/colony count	5	7	6	14	7	11	44	21	24
83970	Assay of parathormone	8	10	6	75	7	6	13	12	58
88342	Immunocytochemistry	7	11	5	8	23	7	1	7	10
80162	Assay of digoxin	17	2	12	12	7	13	33	21	30
82607	Vitamin B-12	10	42	3	5	8	4	43	18	20
82728	Assay of ferritin	49	19	24	23	33	26	62	42	46
82947	Assay of glucose, quant	12	9	17	16	27	20	22	43	41
83718	Assay of lipoprotein	17	14	46	40	17	34	68	34	28
80058	Hepatic function panel	6	4	3	4	15	4	15	4	9

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Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

		Denial Rate (percentage)
		820	824	825	831	832	833	834	835	836	860
CPT Code	Description	N/SD	CO	WY	AK	AZ	HI	NV	OR	WA	NJ
G0001	Venipuncture	4	10	7	4	12	4	10	5	6	4
80061	Lipid panel	8	23	15	16	33	7	26	14	6	29
85025	Automated hemogram	5	17	7	10	21	14	12	8	6	5
84443	Assay TSH	17	32	23	24	41	19	36	25	27	16
80054	Comp metabol panel	5	15	7	5	17	11	9	5	5	4
85024	Automated hemogram	7	8	9	15	6	10	6	12	7	6
84153	Assay of PSA, total^a	53	54	46	36	33	20	35	26	27	21
80092	Thyroid panel w/TSH^b	15	29	17	24	31	19	27	16	20	13
85610	Prothrombin time	5	14	9	10	24	13	24	10	14	10
83036	Glycated hemoglobin test	6	22	12	26	31	17	29	18	5	29
80049	Metabolic panel, basic	4	11	4	6	13	11	12	4	5	3
81000	Urinalysis, nonauto w/scope	12	25	15	7	9	10	21	8	7	10
87086	Urine culture/colony count	10	19	12	7	11	4	7	5	5	15
83970	Assay of parathormone	6	12	5	0	21	14	12	4	9	5
88342	Immunocytochemistry	5	12	11	40	14	5	3	4	9	8
80162	Assay of digoxin	1	13	7	4	15	4	8	4	5	20
82607	Vitamin B-12	50	57	49	3	20	4	11	6	6	5
82728	Assay of ferritin	24	46	39	28	47	17	38	24	32	46
82947	Assay of glucose, quant	10	24	12	22	48	26	44	28	10	25
83718	Assay of lipoprotein	12	42	23	33	36	18	36	23	7	19
80058	Hepatic function panel	5	10	6	19	66	9	75	24	5	4

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Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

		Denial Rate (percentage)
		865	870	880	900	901	902	903	910	951	973
CPT Code	Description	PA	RI	SC	TX	MD	DE	DC	UT	WI	PR/VI
G0001	Venipuncture	4	15	6	5	6	18	5	7	4	6
80061	Lipid panel	20	16	34	13	13	19	27	25	13	7
85025	Automated hemogram	5	34	19	33	33	39	37	36	25	6
84443	Assay TSH	12	27	31	24	25	35	27	48	18	9
80054	Comp metabol panel	4	10	9	6	7	16	5	12	7	7
85024	Automated hemogram	5	8	25	18	21	5	14	24	21	5
84153	Assay of PSA,total^a	18	35	61	21	27	36	31	27	24	23
80092	Thyroid panel w/TSH^b	10	22	72	22	20	35	27	49	54	10
85610	Prothrombin time	6	20	17	15	15	16	18	15	12	6
83036	Glycated hemoglobin test	20	32	16	19	21	25	21	20	11	6
80049	Metabolic panel, basic	4	9	7	4	6	14	4	8	4	5
81000	Urinalysis, nonauto w/scope	6	8	9	7	10	18	9	7	4	6
87086	Urine culture/colony count	9	8	15	15	17	19	24	14	20	6
83970	Assay of parathormone	25	11	13	5	7	4	5	13	5	7
88342	Immunocytochemistry	5	28	12	4	3	1	5	5	4	12
80162	Assay of digoxin	15	9	34	23	24	38	31	17	19	4
82607	Vitamin B-12	4	12	9	9	8	38	5	20	39	5
82728	Assay of ferritin	26	45	30	30	33	47	34	59	21	6
82947	Assay of glucose, quant	15	19	30	22	33	41	39	34	9	23
83718	Assay of lipoprotein	21	28	46	24	19	42	30	36	19	15
80058	Hepatic function panel	3	8	8	5	7	9	4	9	4	7
G0001	Venipuncture	10	8	8	7	15	11	6	11	7	6
80061	Lipid panel	26	18	18	19	14	9	24	41	14	21

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Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

		Denial Rate (percentage)
		2050	5130	5440	5535	10071	10230	10240	10250	10490	11260
CPT Code	Description	CA(T)	ID	TN	NC	RR	CT	MN	MS	VA	MO
85025	Automated hemogram	29	6	61	35	15	9	13	26	6	33
84443	Assay TSH	15	28	34	24	15	13	13	23	14	23
80054	Comp metabol panel	9	7	11	16	15	8	4	8	4	10
85024	Automated hemogram	19	8	32	31	16	9	40	26	7	22
84153	Assay of PSA, total^a	25	40	32	44	15	7	52	34	18	46
80092	Thyroid panel w/TSH^a	20	30	33	27	15	10	11		9	25
85610	Prothrombin time	7	14	14	12	15	7	7	17	8	13
83036	Glycated hemoglobin test	19	23	19	15	15	10	11	7	14	23
80049	Metabolic panel, basic	9	8	8	10	15	12	4	6	3	9
81000	Urinalysis, nonauto w/scope	15	7	11	17	16	13	18	21	13	7
87086	Urine culture/colony count	14	23	20	16	15	7	11	4	8	19
83970	Assay of parathormone	8	3	8	9	12	13	5	12	8	5
88342	Immunocytochemistry	14	8	12	11	24	14	16	12	11	27
80162	Assay of digoxin	9	13	20	27	15	8	12	16	7	16
82607	Vitamin B-12	11	5	11	38	16	11	3	12	7	5
82728	Assay of ferritin	31	42	16	38	13	44	10	20	8	30
82947	Assay of glucose, quant	20	38	29	30	19	13	4	24	18	41
83718	Assay of lipoprotein	16	30	28	20	19	14	21	22	9	25
80058	Hepatic function panel	11	5	9	9	14	10	4	6	4	53

Page 235 Cite Bookmark

Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

		Denial Rate (percentage)
		14330	16360	16510	31140	31142	31143	31144	31145
CPT Code	Description	NY(G)	OH	WV	CA(N)	ME	MA	NH	VT
G0001	Venipuncture	8	6	5	9	4	5	6	5
80061	Lipid panel	15	18	12	37	9	9	12	15
85025	Automated hemogram	24	7	6	12	9	7	11	10
84443	Assay TSH	16	24	16	47	16	15	19	22
80054	Comp metabol panel	7	7	5	14	6	5	10	4
85024	Automated hemogram	20	4	3	6	7	10	10	7
84153	Assay of PSA, total^a	29	24	19	38	27	28	32	38
80092	Thyroid panel w/TSH^b	16	40	37	44	14	10	16	11
85610	Prothrombin time	14	13	12	6	10	7	10	9
83036	Glycated hemoglobin test	14	15	10	10	14	11	16	22
80049	Metabolic panel, basic	4	5	4	8	3	4	5	5
81000	Urinalysis, nonauto w/scope	24	7	3	11	5	9	6	7
87086	Urine culture/colony count	16	14	8	6	17	11	18	16
83970	Assay of parathormone	8	15	4	3	10	5	7	NA
88342	Immunocytochemistry	12	4	3	10	5	11	4	2
80162	Assay of digoxin	17	24	22	7	21	15	19	25
82607	Vitamin B-12	13	7	6	1	8	6	10	4
82728	Assay of ferritin	41	33	27	5	29	19	22	30
82947	Assay of glucose, quant	44	22	15	15	19	25	28	19
83718	Assay of lipoprotein	14	27	20	56	16	21	21	19
80058	Hepatic function panel	6	5	4	69	5	4	7	5

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Suggested Citation: "Appendix E: 1998 Medicare Carrier Denial Rates." Institute of Medicine. 2000. Medicare Laboratory Payment Policy: Now and in the Future. Washington, DC: The National Academies Press. doi: 10.17226/9997.

NOTE: The committee was unable to obtain an explanation for the denials. Since many of the tests with high denial rates are not screening tests, this does not fully explain the high denial rates. Other possible reasons for claims denials include stringent local medical review policies, contractors’ inability to match ICD-9 codes with the appropriate CPT codes due to flaws in their computer programs, duplicative bills for a claim that was already paid, the patient is not eligible for benefits, the provider is not an approved Medicare provider, or the provider is billing for a type of test that is outside the laboratory’s CLIA certification level. There appears to be no obvious pattern to the denial rates. One test that has a high rate of denial in one carrier region will have a very low denial rate in another carrier region.

LMRP = local medical review policy; PSA = prostate specific antigen; TSH = thyroid-stimulating hormone.

^aCoverage was recently extended to screening, once per year.

^bPanel was eliminated in 2000 but there will still be LMRP for each individual test.