Pathology/Lab Coding Alert

Question: We often get orders for hemoglobin A1C tests from physicians for patients with diabetes. Sometimes we get denials related to frequency limitations. How many times per year can you run hemoglobin A1C tests on your patients and still get paid for them?

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Answer: The answer depends on the patient’s condition, so it’s up to the ordering physician to properly implement the frequency guidelines. As a laboratory, you can protect yourselves by understanding these limits and communicating with the ordering physician if lab orders don’t comply or don’t have adequate documentation.

For a stable patient, you can bill Medicare for an A1C test every three months, according to the National Coverage Determination (NCD) for Glycated Hemoglobin/Glycated Protein (190.21)

Physicians may use the A1C test for assessing patients who are capable of maintaining long-term, stable control, so a test every three months will assess whether the patient’s metabolic control has been within the target range on average. The A1C test assesses glycemic control over a period of four to eight weeks.

Exception: You may bill Medicare for A1C tests every one to two months in two cases:

The physician has altered the patient’s diabetes regimen to improve his/her metabolic control

The patient’s level of control was satisfactory previously, but recent events have altered it — for example, the patient has just undergone major surgery or glucocorticoid therapy.

Key: The physician should order the lab test with a diagnosis code that lets your payer know the patient is having a hard time with metabolic control. The diagnosis code’s fifth digit must indicate that the diabetes is uncontrolled. You’ll have a hard time billing frequent tests with uncomplicated Type 2 diabetes code E11.9 (Type 2 diabetes mellitus without complications).