Pathology/Lab Coding Alert

Question: We receive denials from Medicare and some insurance companies when we bill 82985 and 83036 together. Are there any circumstances that warrant both tests, and if so, how could we get paid for them?

Answer: Correct Coding Initiative (CCI) edits bundle 82985 (Glycated protein) and 83036 (Hemoblogin; glytcosylated [A1C]), but you can override the edit pair and bill for both tests in some circumstances.

Physicians order 83036, commonly called a hemoglobin A1C test, to assess long-term glucose control in diabetic patients. The test assesses glycemic control over an eight- to 12-week period. The laboratory National Coverage Determination (NCD) sets a frequency limit of once every three months for this test in controlled diabetics.

The glycated protein test (82985), also called fructosamine, provides more short-term results, assessing glycemic control over a one- to two-week period. Physicians often use this test monthly to monitor glycated protein in pregnant diabetic women or patients with erythrocyte abnormalities. The frequency limit for this test is once a month for pregnant diabetic patients.

Because elevated fetal hemoglobin may interfere with hemoglobin A1C, the lab may need to inform the physician and perform a subsequent glycated protein test. According to the lab NCD, "It is therefore conceivable that a patient will have both a glycated hemoglobin and glycated protein ordered on the same day. This should be limited to the initial assay of glycated hemoglobin, with subsequent exclusive use of glycated protein."

Code both: If the medical record demonstrates medical necessity for performing both tests on the same day, such as the preceding example, then you can bill both codes. You'll need to append modifier 59 (Distinct procedural service) to 83036, which is the column 2 in the CCI edit table.