Pathology/Lab Coding Alert

Question: Our lab performs monthly HbA1C testing for several patients ordered by one specific physician client. We bill the test as 83037 using the diabetes ICD-10 code provided by the ordering physician, but we're having trouble with payment. What could we be doing wrong?

Oklahoma Subscriber

Answer: You should check your payers' coverage determinations for glycosylated hemoglobin A1C (HbA1C) testing for patients with diabetes. Most policies limit the frequency of HbA1C testing, so you could be exceeding that limit, in some cases.

Context: The HbA1C test provides a measure of blood sugar control over a longer period of time, such as three months. Physicians typically order the test once every three to six months, depending on the patient's compliance and ability to control blood sugar, so the monthly regimen seems unusual.

Rates: You mention "trouble with payment," but you don't clarify if that means you're getting denials or that your fees have declined.

CMS changed the payment for 83037 (Hemoglobin; glycosylated (A1C) by device cleared by FDA for home use) for 2018 based on a statutory requirement that the home HbA1C test (83037) garner the same pay as the lab test (83036, Hemoglobin; glycosylated (A1C)). That means CMS set the 2018 payment rate for 83037 at the same rate as 83036 ($11.99) instead of the weighted median for 83037, which was $22.50.

Procedure: Code 83037 doesn't require that the patient do the test at home, but does require that the test is done using a device approved by the FDA for home use. You can use that code if your lab procedure fits that description.