Pathology/Lab Coding Alert

CMS proposes to eliminate 83036 and 83037 pay

After upping the ante on the 2007 fee schedule for 83037, Medicare has proposed a 2008 G code that may take it all away. Let our experts keep you up to date on the changes so you can keep your claims clean.

Code Change Could Compromise Your Pay

At its public meeting for new lab-code pricing held July 16, CMS proposed creating a new HCPCS Level II G code (Gxxxx, Hemoglobin; glycosylated [A1C]) to replace currently used codes 83036 (Hemoglobin; glycosylated [A1C]) and 83037 (Hemoglobin; glycosylated [A1C] by device cleared by FDA for home use).

Depending on CMS- final 2008 pricing for the G code, labs could stand to lose $7.50 for each FDA-approved home-use test -- that's the difference between current fee schedule rates for 83037 ($21.06) and 83036 ($13.56).

-We don't really understand why CMS is proposing a G code for A1C testing after so much effort went into establishing differential pricing for 83037, which is only a 2-year-old code,- says Katharine Ayres, MT (ASCP), CT, director of legislative and regulatory affairs for Clinical Laboratory Management Association (CLMA).

Most professional organizations providing comments at the public meeting, such as CLMA, the College of American Pathologists (CAP), the American Society for Clinical Pathology (ASCP), and the American Clinical Laboratory Association (ACLA), recommended crosswalking Gxxxx to 83036 if CMS insists on implementing the new code.

Avoid Lab Method Distinction

For Medicare beneficiaries, the new G code would no longer allow labs to distinguish between work described by 83036 -- a standard A1C lab test, usually determined by ion-exchange affinity chromatography, immunoassay or agar gel electrophoresis -- and work described by 83037 -- an A1C test using a device cleared for home use by the Food and Drug Administration.

Don't miss: The type of test, not the place of service, distinguishes 83036 from 83037. Whether the testing takes place at a hospital or an independent lab or a physician office, you should report 83037 for a self-contained A1C device that the FDA has approved for home use, such as Bio-Rad Micromat II Hemoglobin A1C, Cholestech GDX A1C Test, Metrika A1C, or Provalis Diagnostics Glycosal HbA1c Test.

Despite the home-use terminology, Medicare won't cover patient self-testing for A1C. Medicare will only cover the test from providers or laboratories certified under the Clinical Laboratory Improvement Amendments (CLIA) with at least a certificate of waiver. You should refer to the waived test list to make sure CLIA approves your particular test kit for this code, and you should append modifier QW (CLIA waived test) to 83037.

Watch for: Expect updates to the CLIA-waived test list and to Medicare coverage policy statements concerning the new G code. That way you-ll know what A1C test kits you can report using the proposed G code and what restrictions, such as frequency limitations, will apply. Also look for the addition of Gxxxx to Medicare's national coverage determination (NCD) for glycated hemoglobin/glycated protein.

Prepare for Administrative Burden -- Here's How

Even if Medicare institutes the G code in 2008 for glycosylated hemoglobin, you won't quit using 83036 and 83037.

-The A1C G code will add an administrative burden for labs, because they-ll have to use the new code for Medicare patients but continue to use 83036 and 83037 for other insurers,- Ayres says.

Don't Miss This Frequency-Limitation Loophole

Documenting medical necessity determines how often you can get paid for A1C testing. 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, according to 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 glycated hemoglobin/glycated protein NCD, which currently lists 83036 as the procedure code. But for uncontrolled diabetes, the physician may test the patient more often.

Important: If a patient receives A1C testing more frequently than once 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 is 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.

Warning: 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.