Pathology/Lab Coding Alert

Reimbursement for blood glucose determinations depends on assigning the proper procedural code based on the testing method, as well as properly applying Medicares coverage policies to these tests. In response to the rising use of glucose monitoring devices approved for home use, Medicare has issued special coverage and payment instructions that must be followed to gain reimbursement.

Coders need to be aware of the criterion for the various blood-glucose codes (e.g., 82947-82952) and especially for the burgeoning home-use glucose meters (82962), says Stan Werner, MT (ASCP), administrative director and corporate compliance officer of Peterson Clinical Laboratory in Manhattan, Kan.

Blood glucose tests are carried out using whole blood, serum or plasma. The blood is typically obtained by fingerstick or vein puncture. When the specimen is taken at the laboratory, the collection service is separately billable as CPT 36415 (routine venipuncture or finger/heel/ear stick for collection of specimen[s]) or G0001 (routine venipuncture for collection of specimen[s]) for Medicare patients, Werner says. But applying the proper code for the glucose test depends on under-standing the methodology.

The glucose determination is made by one of three basic techniques, and this dictates the appropriate procedural code, Werner says. They are as follows:

82947 (glucose; quantitative, blood [except reagent strip]): This is the code often used in clinical laboratories such as ours, and it describes reagent-based blood glucose assays with an end point determined by instrumentation, such as the hexokinase method on an autoanalyzer, Werner explains. These are quantitative tests and are generally more accurate than either the test strips or home-use devices, Werner says.

Although most of these tests are approved only for laboratories with a moderate complexity or higher license, the HemoCue G-Glucose Photometer is approved for labs that are granted waived status under the Clinical Laboratory Improvement Amendments (CLIA) standards. A lab with waived status is not required to meet the more rigorous standards of labs that perform tests of moderate or high complexity. As such, these labs are limited to tests that are simple to perform and low-risk for patient outcome. For a lab with CLIA-waived status, the proper code for this service is 82947-QW (CLIA waived test).

82948 (glucose; blood, reagent strip): This test involves a color comparison of an indicator stick. This is a quick method, but has become less common as the home-use meters have become more prevalent.

82962 (glucose, blood by glucose monitoring device[s] cleared by the FDA specifically for home use): Home-use blood glucose monitoring devices provide a rapid blood sugar reading from a whole blood finger-prick. The instruments operate on enzyme assays or electrochemical methods and spectrophotometry, providing a quick digital readout. Because of the ease of use and the precision of the meter (as opposed to the judgment involved in the colorimetric test strips), these devices are quickly becoming the standard for point-of-care testing, even in the inpatient setting. Many of these tests by various manufacturers are approved for labs with CLIA-waived status.

CPT 2001 includes a new glucose test code, 82945 (glucose, body fluid, other than blood). We used to report the service for glucose determination on specimens such as urine using 82947, because it did not specify the source, Werner says. However, CPT 2001 changed 82947 from glucose; quantitative, to glucose; quantitative, blood (except reagent strip). The new code, 82945, was added for glucose determinations on other fluids, Werner says.

Coding for Postingestion Blood Glucose Tests

Another type of blood glucose test involves taking the measurement following ingestion of glucose by the patient, Werner says. The following codes describe these tests, based primarily on the number of readings taken following glucose ingestion:

82950 glucose; post glucose dose (includes glucose): Use 82950 for blood glucose determinations following the patients ingestion of a dose of glucose. The blood glucose level is normally measured one hour after ingestion.

There has been some confusion about the meaning of the phrase includes glucose in this code, Werner says. The phrase means that the 82950 procedural service includes the cost of the glucose (Glucola) administered to the patient. It does not mean that 82950 includes a pre-dose glucose test. So if a quantitative glucose was ordered for the patient, followed by a glucose dose and a second blood glucose determination, 82947 and 82950 are reported together.

82951 glucose; tolerance test (GTT), three specimens (includes glucose): This test is often given when the physician suspects diabetes mellitus (250.xx), gestational diabetes (648.8x) or other disturbances in carbohydrate metabolism. Typically, blood is drawn for a fasting glucose determination, then the patient ingests a glucose solution before having blood glucose determined again at half-hour and one-hour post-doses. Code 82951 describes these three blood glucose determinations. This code also states includes glucose, referring to the Glucola ingested by the patient, as previously discussed for 82950.

Although each of the three glucose determinations included in 82951 is the same as the service provided in a single determination such as 82947, it is inappropriate to code multiple units of 82947 to describe the glucose tolerance test (GTT).

82952 glucose; tolerance test, each additional beyond three specimens: Often, more than three blood glucose determinations are required for a GTT. Running a three- or four-hour GTT is a fairly standard protocol, Werner says. The glucose measurement for each additional specimen is reported using 82952. Modifier -91 (repeat clinical diagnostic laboratory test) is used for multiple units of the test. Again, it is inappropriate to report 82947 for this service, even though the lab procedure may be the same.

Follow Medicare Rules for Blood Glucose Testing

HCFAs coverage indications and limitations for blood glucose testing are outlined in the proposed national coverage decision published in the March 10, 2000, Federal Register. This document can be obtained at www.access.gpo.gov. A wide array of conditions could indicate the medical necessity of a blood glucose test, including diabetes mellitus (250.xx), carbohydrate metabolism disorders such as hyperglycemia (790.6) and a host of medical conditions that may be a consequence of sustained elevated or depressed blood glucose, such as seizures (780.39), recurrent cystitis (595.9), unexplained skin conditions (e.g., 686.xx), etc. Local medical review policies (LMRPs) for blood glucose testing often include an extensive list of covered ICD-9 codes, as does the proposed national rule. These can be obtained from your carrier, or accessed on the Internet at www.lmrp.net.

Although most LMRPs and the proposed national coverage decision do not prescribe strict frequency limitations for glucose testing, general guidelines are given. The proposed rule states that home blood glucose testing should be encouraged for diabetic patients, but for patients unable to do so, a quantitative blood glucose test may be reasonable and necessary up to four times annually (or perhaps more often depending on patient condition). However, only a single blood glucose test may be considered reasonable and necessary for patients presenting with nonspecific signs and symptoms when the first determination is normal.

Follow Medicare Rules for Blood Glucose Monitoring

Glucose monitoring involves frequent blood tests with an FDA-approved device for home use. Because the purpose of monitoring is to manage insulin therapy (shots, medication and diet), testing often occurs several times a day, far exceeding the previously mentioned four times per year. Medicare Part B may pay for a glucose monitoring device and related supplies for home use under the durable medical equipment benefit. However, a hospital or skilled nursing facility (SNF) is not considered a home under this benefit.

Because of increased claims for glucose monitoring with home-use devices in the hospital, SNF and home health agency (HHA) settings using 82962, Medicare issued a program memorandum regarding coverage for this service (AB-00-108, dated Dec. 1, 2000). The memo states, If home-use glucose monitoring devices are used in the hospital and nursing home settings, a glucose monitoring service must be performed in accordance with laboratory coverage criteria to qualify for separate payment under the Medicare laboratory benefit.

To qualify for coverage in a facility, the home-use glucose monitoring device must be ordered by the physician, and administered by a healthcare provider registered under CLIA with at least a certificate of waiver, says Laurie Castillo, MA, CPC, CPC-H,
CCS-P, member of the National Advisory Board of the American Academy of Professional Coders. Also, the results of the test must be reported promptly to the ordering physician and used to instruct continuation or modification of patient care (including the order for another laboratory service), Castillo says. Standing orders are not generally acceptable documentation for coverage of a laboratory service.

Having met those criteria for coverage, billing for the service will depend on the patients Medicare coverage and the type of facility, Castillo says. For patients eligible for services under Medicare Part B but not covered by Part A, different billing and reimbursement arrangements are in effect for hospitals, SNFs and HHAs.

The 82962 glucose monitoring service for a hospital patient is submitted to the intermediary using UB-92 (HCFA 1450 form), type of bill (TOB) 12x, revenue code 30x, and is paid under the clinical laboratory fee schedule, Castillo says. In an SNF, if the patient is in a certified bed, the procedure is billed on the UB-92, TOB 22x, with revenue code 30x for reimbursement at reasonable cost, which must be reflected in the laboratory cost center. However, if the patient is in a non-certified bed, the service is billed on the UB-92, TOB 23x, revenue code 30x, and reimbursed under the clinical laboratory fee schedule, Castillo says.

Often, patients in an HHA will self-administer the glucose monitoring, even if an employee has to supervise and assist the patient, Castillo says. This service is not separately billable as a laboratory test but is considered encompassed in the home health service. However, if the lab test meets the laboratory coverage criteria outlined above, it is separately billable for a patient covered under Medicare Part B but not Part A. The HHA must have a supplier number, and submit HCFA form 1500 to the Medicare carrier, Castillo says.

Under any of these arrangements involving glucose monitoring of a diabetic patient, the physician may also order a separate quantitative blood glucose test from venous blood. This procedure is separately reported using the appropriate code, such as 82947.