Pathology/Lab Coding Alert

Question: What are the coverage rules for Medicare's diabetes screening coverage?


Georgia Subscriber

Answer: Medicare covers diabetes screening for patients with any one of the following risk factors:

- Hypertension
- Dyslipidemia
- Obesity (a body mass index greater than or equal to 30 kg/m2)
- Previous identification of an elevated impaired fasting glucose or glucose intolerance.

Or at least two of the following characteristics:

- Overweight (a body mass index greater than 25 but less than 30 kg/m2)
- Family history of diabetes
- Age 65 or older
- History of gestational diabetes mellitus or delivery of a baby weighing greater than 9 pounds.

Or patients diagnosed with pre-diabetes -quot; a condition of abnormal glucose metabolism diagnosed from a previous fasting glucose level of 100-125 mg/dL or a two-hour post-glucose challenge of 140-199 mg/dL.

Frequency: Rules limit testing to one diabetes screening per year for patients who have never been tested or who have been previously tested and not diagnosed with pre-diabetes. Coverage rules allow two diabetes screening tests per year for beneficiaries previously diagnosed with pre-diabetes.

You can't bill for the screening benefit if a physician has already diagnosed the patient with diabetes--any glucose testing in this case is diagnostic.

Tests: The screening tests include 82947 (Glucose; quantitative, blood [except reagent strip]) and 82950 (Glucose; post glucose dose [includes glucose]) or 82951 (Glucose; tolerance test [GTT], three specimens [includes glucose]). If the patient meets Medicare's definition of pre-diabetes, you should report the appropriate test code with modifier TS (Follow-up service). Medicare will not allow the increased frequency testing without the modifier.

Diagnosis: You should use V77.1 (Special screening for diabetes mellitus) to indicate the reason for the test.