Medicare Compliance & Reimbursement

Billing at least once per year for all patients now allowed.

The Medicare Modernization Act (MMA) rang in the New Year with far-reaching reimbursement changes that open the door for annual diabetes screens for patients - and bi-annual ones for those who qualify.

"Before this, Medicare patients were refused screening [for diabetes] except for certain procedures," explains Margaret Ann Hyder, lab manager for Clinical Laboratory Services in Lincolnton, NC.

Good news: The screening benefit, effective Jan. 1, allows for one test per year for patients not previously diagnosed with diabetes. That means a diabetes screen can become part of patients' annual physicals, Hyder asserts.

The rules are especially helpful for those at risk for developing diabetes, points out Maggie Mac, a health care consultant with Pershing, Yoakley & Associates in Clearwater, FL. Medicare says it will consider patients to be "at risk" if they present with at least one of the following symptoms:
  hypertension;
  dyslipidemia;
  obesity (BMI of 30 kg/m2 or more);
  previously identified elevated fasting glucose;
  previously identified impaired glucose tolerance; or
 
Medicare will also consider patients at-risk when they have two or more of the following symptoms:
  BMI between 25 and 30 kg/m2;
  family history of diabetes;
  history of gestational diabetes or delivery of 9-pound or larger baby; or
  65 years of age or older. Patients who display any of these symptoms qualify for a bi-annual diabetes screen no fewer than six months from their first test.

Labs must use a CPT code plus the diagnosis code V77.1 (Special screening for diabetes mellitus) to report a diabetes screening test. To report six-month screens, use the V77.1 diagnosis code, the correct CPT code and the HCPCS modifier -TS (Follow up service), stresses Anne Pontius, president of Laboratory Compliance Consultants in Raleigh, NC. Without the mod, Medicare doesn't know that this claim fell into the at-risk column.