Part B Insider (Multispecialty) Coding Alert

Make sure your fifth digit supports uncontrolled diagnosis

Question: How many times per year can you run hemoglobin A1C tests on your patients and still get paid for them? Quarterly? Twice a year?


Missouri subscriber

Answer: It depends on the patient's condition, says Jenifer Cox with Fairview Red Wing Medical Center in Red Wing, MN. For a stable patient, you can bill Medicare for an A1C test every three months, according to the National Coverage Determination (NCD) on the Centers for Medicare & Medicaid Services (CMS) Web site. (-NCD for Glycated Hemoglobin/Glycated Protein,- 190.21)

You use the A1C test for assessing patients who are -capable of maintaining long-term, stable control,- CMS says. So a test every three months will assess whether the patient's metabolic control has been within the target range on average. The A1C test assesses glycemic control over a period of four to eight weeks, CMS notes.

But you can bill Medicare for A1C tests every one to two months in two cases:

- The physician has altered the patient's diabetes regimen to improve his/her metabolic control.

- The patient's level of control was satisfactory previously, but recent events have altered it. (For example, the patient has just undergone major surgery or glucocorticoid therapy.)

Also, monitoring glycated hemoglobin (which CMS says is equivalent to A1C) monthly in pregnant diabetic women may be useful.

Tip: Try attaching modifier QW (for CLIA waived tests) to the hemoglobin A1C testing code, says coder Johra Master.

Bottom line: Some patients are harder to control than others, says Dianne Wilkinson, compliance officer and quality manager with MedSouth Healthcare in Dyers-burg, TN.

The key is to use a diagnosis code that lets your carrier know the patient is having a hard time with metabolic control. Your diagnosis code's fifth digit has to indicate that the diabetes is uncontrolled. You-ll have a hard time billing frequent tests with regular Type 2 diabetes code 250.00, Wilkinson notes.

Also: Physicians are sometimes careless about diabetes coding in general, Wilkinson warns. If the patient has diabetic nephropathy or some other manifestation, make sure you-re listing the correct diabetes code first, with an accurate fourth digit. And then list the manifestation code second, she adds.