Pathology/Lab Coding Alert

Question: Our lab has very inconsistent results with getting paid for glycosylated hemoglobin tests whether we report 83036 or 83037. What could be the problem?

Washington Subscriber

Answer: You are correct that you can report the test with one of two CPT codes: 83036 (Hemoglobin; glycosylated [A1C]) or 83037 (Hemoglobin; glycosylated [A1C] by device cleared by FDA for home use). If the lab performs a standard A1C lab test, usually using ion-exchange affinity chromatography, immunoassay or agar gel electrophoresis, report 83036. If the lab (usually in the physician's office) uses the FDA-approved device, you should report 83037.

Your payment problem most likely stems from coverage and frequency rules, not from your CPT code selection. Medicare's National Coverage Determination (NCD) for glycated hemoglobin provides frequency guidelines for patients who are capable of maintaining long-term, stable glycemic control: -Measurement may be medically necessary every three months to determine whether a patient's metabolic control has been, on average, within the target range.-

According to the NCD, -More frequent assessments, every one to two months, may be appropriate in the patient whose diabetes regimen has been altered to improve control or in whom evidence is present that intercurrent events may have altered a previously satisfactory level of control.- Events that might alter glycemic control include major surgery or glucocorticoid therapy, for instance.

If your lab performs A1C testing more than four times a year, the ordering physician must document lack of glycemic control to show medical necessity for the test. That means using a diabetes code (250.xx) with the fifth digit of 2 (type II or unspecified type, uncontrolled) or 3 (type I [juvenile type], uncontrolled).