Pathology/Lab Coding Alert

Hint: Associated conditions warrant test

When physicians order glycated protein instead of glycosylated hemoglobin to evaluate diabetic glucose control, you need to understand medical necessity for the test if you want to get paid.

Although Medicare’s National Coverage Determination (NCD) for glycated hemoglobin/glycated protein lists the same covered ICD-9 codes for both tests, the narrative describes different indications and frequencies for each.

A Rose by Any Other Name …

The glycated protein test measures glycosylated protein present in serum or plasma. But if you get an order for fructosamine, look no further than 82985 (Glycated protein)--the tests are one and the same. 

The lab test measures the component of the specific protein that is glycated in the blood, usually by colorimetric method or affinity chromatography.

Know Indications for Glycated Protein

Physicians may order glycated protein in place of A1C (83036, Hemoglobin; glycosylated [A1C]; or 83037, Hemoglobin; glycosylated [A1C] by device cleared by FDA for home use) to manage certain diabetic patients. Glycated protein is particularly useful in patients who have abnormalities of erythrocytes, such as hemolytic anemia or hemoglobinopathies.

Glycated protein (82985) provides more short-term results than glycosylated hemoglobin, assessing glycemic control over a one- to two-week period, says Joan Logue, BS, MT(ASCP), principal with Health Systems Concepts Inc. in Longwood, Fla. Physicians often use this test monthly to monitor glycated protein in pregnant diabetic women, she adds.

Do this: When the ordering physician documents conditions such as pregnancy or hemolytic anemia along with diabetes, you should include the appropriate ICD-9 code to show medical necessity for the glycated protein test.

For instance, you should report diabetes in a pregnant woman using one of the following codes from category 648.x (Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth or the puerperium):

648.0x--Diabetes mellitus

Or for gestational diabetes:

648.8x--Abnormal glucose tolerance.

You must also apply the appropriate fifth digit for complications of diabetes and pregnancy:

0--unspecified as to episode of care or not applicable

3--antepartum condition or complication

4--postpartum condition or complication.

Follow frequency guidelines: According to the lab NCD, “It may be reasonable and necessary to monitor glycated protein monthly in pregnant diabetic women.” That’s why documenting diabetes in pregnancy using the correct ICD-9 code should ensure payment for monthly 82985 charges when a category 250.x (Diabetes mellitus) code might not.
 
You Might Get Paid for Both Tests

You may encounter a situation that demonstrates medical necessity for both 83036 and 82985 on the same day. According to the NCD for glycated hemoglobin/glycated protein:

“Many methods for the analysis of glycated hemoglobin show significant interference from elevated levels of fetal hemoglobin .... Alternative testing, including glycated protein, may be indicated to monitor the degree of glycemic control in this situation. It is therefore conceivable that a patient will have both a glycated hemoglobin and glycated protein ordered on the same day. This should be limited to the initial assay of glycated hemoglobin, with subsequent exclusive use of glycated protein.”

Problem: A National Correct Coding Initiative edit bundles these two codes if you bill them on the same day, Logue says.

Solution: If both tests are truly medically necessary, use modifier 59 (Distinct procedural service) to unbundle the codes and recoup payment for both, Logue says.