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Pathology/Lab Coding Alert

Get Ready to Recoup Pay for Diabetes, Heart Disease Screening

Published on Mon Sep 27, 2004

Medicare proposes glucose and lipid test coverage for 2005

Soon you won't always need signs, symptoms, or disease diagnoses to get paid for 82947 and 80061. Medicare's proposed heart disease and diabetes screening rules tell you when the agency will cover these and other lab tests, and how to document the reason for the tests so your lab can get reimbursement starting Jan. 1, 2005.

Last year's Medicare Modernization Act called for adding heart disease and diabetes screening, and CMS answered the call in the 2005 Physician Fee Schedule proposal published in the Aug. 5, 2004, Federal Register. You can access the proposed rule on the Internet at http://www.access.gpo.gov/su_docs/fedreg/a040805c.html.

Here's How to Show Medical Necessity for Diabetes Screening

You'll have to document screening diabetes tests differently from diagnostic tests. "Medicare wants to see a screening diagnosis code so that the claim falls under the screening coverage rules," says Stan Werner, MT (ASCP), administrative director of Peterson Clinical Laboratory in Manhattan, Kan.

Do this: Use ICD9 V77.1 (Special screening for diabetes mellitus) to report a screening test ordered for a patient at risk for diabetes.

Medicare says that it will consider patients with at least one of the following conditions to be "at risk" for developing diabetes:

1. Hypertension

2. Dyslipidemia

3. Obesity (body mass index [BMI] of 30 kg/m2 or more)

4. Previously identified elevated fasting glucose

5. Previously identified impaired glucose tolerance

6. Two or more of the following:

a) BMI between 25 and 30 kg/m2

b) Family history of diabetes

c) History of gestational diabetes or delivery of 9-pound or larger baby

d) 65 years of age or older.

Watch out: Don't code for a screening diabetes test if the patient shows symptoms of uncontrolled diabetes, such as excessive thirst (783.5, Polydipsia) or frequent urination (788.41, Urinary frequency). Those conditions are already covered under lab National Coverage Determinations or diagnostic diabetes testing.

Requirement: You can't exceed frequency limitations for diabetes screening tests. Medicare proposes allowing two screening tests per 12-month period for patients with "pre-diabetes" (previous fasting glucose of 100-125 mg/dL, or a 2-hour post-glucose challenge of 140-199 mg/dL). Without pre-diabetes, Medicare would cover a patient's diabetes screening test only once a year.

Use 82947 and 82951 for Diabetes Screening Tests

Medicare proposes covering two different tests for diabetes screening: 82947 (Glucose; quantitative, blood [except reagent strip]) and 82951 (Glucose; tolerance test [GTT], three specimens [includes glucose]). Note that Medicare would cover one or the other of the tests for screening, not both.

Look for Medicare to Cover Heart-Disease Screening

Under Medicare's proposal, you can expect payment for all beneficiaries age 20 years or older for three screening blood tests that measure conditions associated with cardiovascular disease:

  •  82465 - Cholesterol, serum or whole blood, total

  •  83718 - Lipoprotein, direct measurement; high- density cholesterol (HDL cholesterol)
  •  84478 - Triglycerides.

    Because these three tests comprise a panel with a separate CPT code, you should report the tests using the following code when ordered together as a panel:

  •  80061 - Lipid Panel.

    Warning: Don't exceed Medicare's frequency limitation of once every five years for these heart-disease screening tests. Some in the lab community think that's too long, Werner says, but physicians will have to stick to this schedule if the patient has no indications for a diagnostic test. 

    You Can Only Report Certain Tests for Screening

    Don't expect Medicare to pay for other tests that physicians might order to screen for heart disease. For example, Medicare doesn't cover a separate low-density lipoprotein test (83721, Lipoprotein, direct measurement; LDL cholesterol), since the LDL cholesterol can usually be calculated from the results of other tests in the lipid panel, Werner says.

    LDL cholesterol isn't the only test that didn't make Medicare's coverage list to screen for cardiovascular disease. "Medicare's screening proposal also doesn't cover C-reactive protein (86140) or other tests that some professional societies recommended for coverage," says Elissa Passiment, EdM, CLS(NCA), executive director of the American Society for Clinical Laboratory Science.

    Tip: Don't confuse Medicare's coverage for screening lipid tests with reimbursement for diagnostic tests. "Medicare pays for more diagnostic tests and covers testing at a frequency greater than once every five years for patients with signs, symptoms or diagnoses that indicate medical necessity for those tests," Werner says. Medicare's National Coverage Determination for lipid testing describes the procedure and diagnosis codes for diagnostic tests.

    List Different ICD-9 Codes for Screening Heart Tests

    You'll need to inform your physician clients that they must order a screening lipid panel using one of the following ICD-9 codes:

  •  V81.0 - Special screening for ischemic heart disease

  •  V81.1 - Special screening for hypertension
  •  V81.2 - Special screening for other and unspecified cardiovascular conditions.

    Medicare requires labs to report the approved lipid tests with one of these ICD-9 codes when ordered for the purpose of cardiovascular screening.

    But if the physician orders a lipid panel (80061) for a patient diagnosed with obesity (278.00, Obesity, unspecified) or hypertensive heart disease (402.00-402.91), for example, it is not a screening test, and you should not report a V code as the reason for the test. List the physician's ordering diagnosis, and check that code against Medicare's "covered list" for the lipid testing NCD.

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