Pathology/Lab Coding Alert

Watch out:  Physician must document reason for frequent A1C

Diabetes management may require hemoglobin A1C testing--but you won't get paid if you miss the frequency mark.

You may know the test by various names: glycated or glycosylated Hgb, or A1C. You can use the 2006  A1C code changes to refresh your skills for reporting this service.

The American Diabetes Association (ADA) recommends that in addition to patients monitoring their blood glucose levels at home, they should also receive hemoglobin A1C testing. The latter test reveals the patient's average blood glucose level, or glycemic control, over the preceding four to eight weeks. The lower the patient's value, the better he is maintaining normal blood sugar.

"Hemoglobin A1C is the standard for monitoring type 1 and type 2 diabetes," says Nathaniel Clark, MD, MS, RD, of the ADA.

Learn CPT 2006 Code Changes

To better reflect current nomenclature, CPT 2006 changed the word "glycated" to "glycosylated" for 83036 (Hemoglobin; glycosylated [A1C]). The physician might also order the test as "hemoglobin A1C."

Don't miss: The U.S. Food and Drug Administration recently approved a home-use device for measuring glycosylated hemoglobin. If you use the devise for point-of-care testing, you should report the service with new code CPT 83037 (Hemoglobin; glycosylated [A1C] by device cleared by FDA for home use).

Physicians find having A1C results available valuable during the patient visit. That's why they might have the patient test at home or may offer point-of-care testing using the FDA-approved device. You should report these tests as 83037.

Otherwise, the lab often receives a request for the test a few days before the physician visit and reports 83036 for the standard A1C lab test, usually determined by ion-exchange affinity chromatography, immunoassay, or agar gel electrophoresis. Then the physician may counsel the patient about the test results at the visit.

Watch Frequency Limits

Medicare's National Coverage Determination (NCD) for glycated hemoglobin provides frequency guidelines for patients who are capable of maintaining long-term, stable glycemic control: "Measurement may be medically necessary every three months to determine whether a patient's metabolic control has been, on average, within the target range."

Diabetes experts agree. Physicians should order the A1C test every three to six months with a target of under 7 percent, says Beverly Dyck Thomassian, RN, MPH, BC-ADM, CDE, a diabetes educator in Chico, Calif.

But what if the patient doesn't have long-term, stable glycemic control? According to the NCD, "More frequent assessments, every one to two months, may be appropriate in the patient whose diabetes regimen has been altered to improve control or in whom evidence is present that intercurrent events may have altered a previously satisfactory level of control." Events that might alter glycemic control include major surgery or glucocorticoid therapy, for instance.
 
Key: How frequently you can bill 83036 or 83037 depends on the reason for the test and the patient's medical status. If you bill one of these codes more often than covered based on the NCD or other payer guidelines, you won't get paid.

In other words, carriers base the frequency rules on the patient's diagnosis. That means you'll have to be familiar with the ICD-9 codes.

Don't Forget Diabetes 5th Digit

Because the frequency rules depend on whether the patient has long-term, stable glycemic control, your diagnosis code must reflect this information if you want to get paid for A1C testing. That's why you have to be sure your diabetes code includes a fifth digit. In addition to specifying type I or type II diabetes, the fifth digit also indicates whether the diabetes is controlled or uncontrolled.

Here's how: Use the following fifth-digit subclassification with category 250 (Diabetes mellitus):

0--type II or unspecified type, not stated as uncontrolled
1--type I (juvenile type), not stated as uncontrolled
2--type II or unspecified type, uncontrolled
3--type I (juvenile type), uncontrolled.

Select the appropriate diabetes four-digit code based on the complications, if any, and then assign the appropriate fifth digit to indicate diabetes type and control.

Caution: Don't let insulin use fool you into thinking you must report type I diabetes. You can report 0 or 2 as the fifth digit even if the patient requires insulin, according to ICD-9 instructions. You should additionally report V58.67 (Long-term [current] use of insulin) in those cases.

The bottom line: If the physician reports uncontrolled diabetes and you report the appropriate fifth digit (2 or 3), you can expect to get paid for A1C testing more frequently than four times a year. Your documentation must show lack of glycemic control to demonstrate medical necessity for more frequent testing.