Pathology/Lab Coding Alert

Don't forget CLIA certification info

 Fiction: Choosing 83036 or 83037 for hemoglobin A1C depends on where you perform the test.
 
Fact: You can report 83037 regardless of location -- as long as you use a test that is Food and Drug Administration-approved for home use.
 
Why you should care: Home-approved 83037 pays $21.06 on the Clinical Laboratory Fee Schedule (CLFS) -- compared to $13.56 for 83036.

-Home-Approved- Doesn't Mean -Home-Required-

 You may find the 83037 code descriptor confusing: Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use. But the -home use- part just means that you need to make sure your lab uses one of the devices the Food and Drug Administration (FDA) approved for use at home before reporting 83037, experts say.
 
Part B carrier Noridian Medicare put out a coverage notice saying you can bill either A1C test code 83036 (Hemoglobin; glycosylated [A1C]) or 83037 in a physician-office lab. The main difference is that 83037 describes -devices cleared by the FDA for home use.- So you should be careful not to use 83037 if your lab uses a -desk-top analyzer- or other device that the FDA hasn't approved for use at home, Noridian says.
 
Good news: In 2006, more than half of Medicare carriers paid only $13.56 for 83037, but in 2007 the code reimburses about $21.06 nationwide.

Choose the Right Code

 Many physicians want A1C test results available during the patient visit. That's why they might 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.

Don't Forget CLIA

 Despite the home-use terminology, Medicare won't cover patient self-testing for A1C, Noridian adds. Medicare will cover the test from only providers or laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA).
 
Important: You should append modifier QW (CLIA waived test) to 83037 and make sure your lab has its own CLIA certificate before using this code, says Marie West with Medical Data Services in Edmund, Okla. You should refer to the most current CLIA waived test list to make sure your particular test kit is OK to bill using this code, she adds. You can find the most current list on the Internet at www.cms.hhs.gov/transmittals/downloads/
R1197CP.pdf.
 
The list now includes the following tests reportable to 83037-QW:

 - Bio-Rad Micromat II Hemoglobin A1c Prescription Home Use Test (manufacturer, Bio-Rad Laboratories)
 
- Cholestech GDX A1C Test (Prescription Home Use) (manufacturer, Cholestech Corporation)
 
- Metrika A1c Now for Prescription Home Use (K020234) (manufacturer, Metrika Inc.)

 - Provalis Diagnostics Glycosal HbA1c Test (manufacturer, Provalis Diagnostics Ltd.)
 
- Provalis Diagnostics In2it In-Office Analyzer (II) A1C Prescription Home Use Test System (manufacturer, Provalis Diagnostics Ltd.)

 Beware using 83037 for non-home-use tests:
Noridian says that if you bill a -relatively high volume of A1C tests- and use 83037 for some of them, you may have to -produce invoices- to prove you used A1C test kits that the FDA approved for home use.

Watch Frequency Limits

 The American Diabetes Association (ADA) recommends that in addition to patients monitoring their blood glucose levels at home, they should receive glycosylated hemoglobin (A1C) testing. The A1C test reveals the patient's average blood glucose level, or glycemic control, over the preceding four to eight weeks.
 
-Hemoglobin A1C is the standard for monitoring type I and type II diabetes,- says Nathaniel Clark, MD, MS, RD, of the ADA.
 
If the patient's diabetes is under control, the physician should order an A1C test only once every three months, according to Medicare's national coverage determination (NCD). But for uncontrolled diabetes, the physician may test the patient more often.
 
Important: If your doctor is performing A1C testing more than every three months, you need to document the reason, experts say. Your documentation should discuss the patient's lack of glycemic control. Pay attention to the fifth digit of your diagnosis coding, because in addition to identifying type I or type II diabetes, the fifth digit specifies whether the patient's diabetes was controlled or uncontrolled.

 Here's how: Use the following fifth-digit subclassification with category 250.x (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.