Medicare Compliance & Reimbursement

Diabetes, heart disease screening changes will help labs in 2005.

Next year labs won't always need signs, symptoms or disease diagnoses to get paid for 82947 and 80061.

Medicare's proposed heart disease and diabetes screening rules explain when the Centers for Medicare & Medicaid Services will cover these and other lab tests, and how to document the reason for the tests so labs can get reimbursed starting as early as Jan. 1, 2005. 

Last year's Medicare Modernization Act called for adding heart disease and diabetes screening, and CMS answered the call in the 2005 Physician Fee Schedule proposal published in the Aug. 5, 2004, Federal Register.

Labs will need to document screening diabetes tests differently from diagnostic tests. "Medicare wants to see a screening diagnosis code so that the claim falls under the screening coverage rules," says Stan Werner, administrative director of Peterson Clinical Laboratory in Manhattan, KS.

Use V77.1 (Special screening for diabetes mellitus) to report a screening test ordered for a patient at risk for diabetes. Medicare says it will consider patients with at least one of the following conditions to be "at risk" for developing diabetes:

1. Hypertension

2. Dyslipidemia

3. Obesity

4. Previously identified elevated fasting glucose

5. Previously identified impaired glucose tolerance

6. Two or more of the following:

a) BMI between 25 and 30 kg/m2

b) Family history of diabetes

c) History of gestational diabetes or delivery of a 9 pound or larger baby 

d) 65 years of age or older.

When The Screening Code Isn't Right

Don't code for a screening diabetes test if the patient shows symptoms of uncontrolled diabetes, such as excessive thirst (783.5, Polydipsia) or frequent urination (788.41, Urinary frequency). These conditions are already covered under the National Coverage Determinations or diagnostic diabetes testing. 

Labs must not exceed frequency limitations for diabetes screening tests. Medicare proposes allowing two screening tests per 12-month period for patients with "pre-diabetes" (previous fasting glucose of 100-125 mg/dL, or a 2-hour post-glucose).

Medicare requires labs to report the approved lipid tests with one of these ICD-9 codes when ordered for the purpose of cardiovascular screening. But if the physician orders a lipid panel (80061) for a patient diagnosed with obesity (278.00, Obesity, unspecified) or hypertensive heart disease (402.00-402.91), for example, it is not a screening test, and labs should not report a V code as the reason for the test. List the physician's ordering diagnosis, and check that code against Medicare's "covered list" for the lipid testing NCD.