Part B Insider (Multispecialty) Coding Alert

Recoup up to $17 for diabetes screening test

If your physician isn't documenting specified risk factors and coding one of three specified glucose tests with the diabetes screening V code when he performs diabetes screening, his claim could come back negative - for payment, that is.

Important: As the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA) requires, Medicare began paying for most diabetes screenings (82947, 82950, 82951) as of Jan. 1, 2005. In the past, Medicare did not reimburse physicians for diabetes screenings.

CMS will reimburse "diabetes screening tests at the same amounts paid for these tests when performed to diagnose an individual with signs and symptoms of diabetes," according to the Nov. 15, 2004, Federal Register.

Translation: Expect your Medicare insurer to pay $6 to $17 for the tests, according to the Clinical Laboratory Fee Schedule .

Teach Physicians To Order Tests

One problem physicians' offices - and their patients - face when Medicare issues new coverage decisions is that the physicians either are unaware, forget or ignore the decisions.

"Our difficulty [with the diabetes screening tests] is getting the doctors to remember they can do them," says Cathy Satkus, a professional coder for Harvard Family Physicians, an internal medicine and family practice in Tulsa, OK. "With so many new rules and tests/screenings added, it is difficult to get the doctors to remember what tests they can now do."

What to do: If your physicians are too busy to read this article, give them our handy Cheat Sheet that highlights the screening codes and other important features.

Another problem: Many offices aren't sure when to bill for lab tests. Remember that if you sent the blood specimen to an outside lab, you should report only a venipuncture (36415, Collection of venous blood by venipuncture). But if your office has an appropriately licensed lab, you can bill for the glucose test and the venipuncture, says Kathy Pride, CPC, CCS-P, a coding consultant for QuadraMed in Port St. Lucie, FL.

Remember: You may not bill Medicare for G0001 (Routine venipuncture for collection of specimens); CMS deleted the code back in January.

Append Modifiers -QW and -TS If Applicable

If your physician wants to screen a Medicare patient for diabetes, he should use either the fasting blood glucose test, the post-glucose challenge test or the glucose tolerance test.

To code the fasting blood test, you should assign 82947 (Glucose; quantitative, blood [except reagent strip]). The post-glucose test requires 82950 (... post glucose dose [includes glucose]), and the glucose tolerance requires 82951 (... tolerance test [GTT], three specimens [includes glucose]). Medicare pays for only one test, so you should submit only one of the above codes.

ICD-9 coding: When you use 82947, 82950 or 82951, you should list V77.1 (Special screening for diabetes mellitus) as your primary diagnosis code, according to CMS.

Modifier tip #1: The three Medicare-approved diabetes-screening tests carry a "waived status." That means if your office has obtained the Clinical Laboratory Improvement Amendments (CLIA) certification, your physician can perform the tests in the office. Be sure you attach modifier -QW (CLIA waived test) to the codes (for example, 82950-QW).

If your office doesn't have CLIA certification, your physician won't perform the tests, but a lab will, and you cannot bill for lab work performed outside of your office, says Bruce Rappoport, MD, CPC, who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, FL-based accounting firm with healthcare expertise.

Modifier tip #2: If the physician performs a screening test on a patient with "prediabetes," Medicare requires that you attach modifier -TS (Follow-up service) to the CPT code. Therefore, if your physician performed the glucose tolerance test on a prediabetes patient, you would report 82951-QW-TS.

Private-payer watch: Don't assume commercial insurers will follow Medicare's lead on the screening coverage. In fact, most private carriers won't accept diabetes screening or any other screening codes, Satkus warns. For example, one of her payers requires her office to report venipuncture code 36415 (Collection of venous blood by venipuncture), even though her office performs the tests with an in-house lab. 

Report Required Risk Factors

You may bill one test every six months for patients with "prediabetes." But you should report only one test every 12 months for patients whom the physician has not diagnosed with prediabetes, or whom a physician has never tested, according to Medicare guidelines.

Also, before you report the screening codes, be sure the patient has at least one of the following risk factors for diabetes: