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Pathology/Lab Coding Alert

Scrutinize Diagnoses Before You Bill Screening Tests

Published on Sun Jan 02, 2005

"V" codes show medical necessity for diabetes, heart disease

Now your lab can get paid for diabetes and cardio-vascular (CV) disease screening by following Medicare's new rules. You'll need to link the proper ICD-9 and CPT codes and only report the tests as often as Medicare allows - otherwise you'll need an Advance Beneficiary Notice (ABN) for the service.

Medicare clarifies coding issues and finalizes criteria for screening tests physicians order beginning Jan. 1. You can find the new rules in the 2005 Physician Fee Schedule, published in the Nov. 15, 2004 Federal Register and available on the Internet at http://www.access.gpo.gov/su_docs/fedreg/a041115c.html.

No New "G" Codes for Screening

Unlike many other screening tests reported to Medicare, you won't use temporary "G" codes to bill screening for diabetes and CV disease. "Labs currently use HCPCS Level II codes to report most screening tests to Medicare, even when a CPT code accurately describes the same test," says Mary Jo Bonifas, MT (ASCP), manager of laboratory services at United Clinical Laboratories in Dubuque, Iowa. That's because Medicare in many cases requires a two-tiered coding system, instructing labs to report tests such as prostate specific antigen (PSA) with a "G" code for screening (G0103, Prostate cancer screening; prostate specific antigen test [PSA], total) and a CPT code for the same test for diagnosis (84153, Prostate specific antigen [PSA]; total). You also currently distinguish between CPT codes and HCPCS Level II codes ("G" or "P") for diagnostic vs. screening Pap tests.

But CMS says it's working toward phasing out "G" codes, thanks in part to the Health Insurance Portability and Accountability Act (HIPAA) standardization requirements for code sets. So for diabetes and CV disease screening, Medicare instructs labs to report specific screening ICD-9 codes linked to the approved lab-test CPT codes to indicate a screening test. Note that using the CPT code means that Medicare will pay for the screening lab test at the same rate as a diagnostic lab test ordered with the same code - the rate designated on the Clinical Laboratory Fee Schedule.

"V" Codes Show Screening Medical Necessity

Instead of "G" procedure codes, you should use a CPT code plus "V" diagnosis codes to document screening diabetes and CV disease tests. "Medicare wants to see a screening diagnosis code so that the claim falls under the screening coverage rules," says Elissa Passiment, EdM, CLS (NCA), executive director of the American Society for Clinical Laboratory Science (SSCLS).

Do this for diabetes: Use V77.1 (Special screening for diabetes mellitus) to report a screening test for a patient at risk for diabetes.

Medicare says that it will consider patients with at least one of the following conditions to be "at risk" for developing diabetes:

1. Hypertension
2. Dyslipidemia
3. Obesity (body mass index [BMI] of 30 kg/m2 or more)
4. Previously identified elevated fasting glucose
5. Previously identified impaired glucose tolerance
6. Two or more of the following:
a) BMI between 25 and 30 kg/m2
b) family history of diabetes
c) history of gestational diabetes or delivery of 9-pound or larger baby
d) 65 years of age or older

Do this for CV disease:

You'll need to inform your physician clients that they must order a screening lipid panel or component tests using one of the following ICD-9 codes:

  •  V81.0, Special screening for ischemic heart disease
  •  V81.1, Special screening for hypertension
  •  V81.2, Special screening for other and unspecified cardiovascular conditions.

    Watch Out: Don't code for a screening diabetes test if the patient shows symptoms of uncontrolled diabetes, such as excessive thirst (783.5, Polydipsia) or frequent urination (788.41, Urinary frequency). Laboratory National Coverage Determinations (NCDs) already cover those conditions for diagnostic diabetes testing.

    Also, don't confuse Medicare's rules for screening lipid tests with coverage for diagnostic tests. "Medicare pays for more diagnostic tests for patients with signs, symptoms or diagnoses that indicate medical necessity for those tests," Passiment says. Medicare's National Coverage Determination (NCD) for Lipid testing describes the procedure and diagnosis codes for diagnostic tests.

    You Can Use 82950, Blood Sample for Diabetes

    Medicare's proposed rule published in Aug. 2004 seemed to exclude payment for a common diabetes screening "post glucose" test. But the final rule clarifies that CMS will cover this test, not just a fasting glucose or glucose tolerance test (GTT). The CPT codes that Medicare covers for diabetes screening are as follows:

  •  82947 (Glucose; quantitative, blood [except reagent strip])
  •  82950 (Glucose; post glucose dose [includes glucose])
  •  82951 (Glucose; tolerance test [GTT], three specimens [includes glucose]).

    Note that Medicare would cover only one of the tests for screening.

    The final rule also clarifies the specimen source for a fasting glucose test (82947). The proposed rule indicated that Medicare would cover a "fasting plasma glucose test," but the final rule changes the terminology to "fasting blood glucose test" to coincide with CPT terminology.

    Don't Reflex to LDL

    When your lab performs CV-disease screening, Medicare will cover all of the following three tests:

  •  82465, Cholesterol, serum or whole blood, total
  •  83718, Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
  •  84478, Triglycerides

    Because these three tests comprise a panel with a separate CPT code, you should report the tests using 80061 (Lipid panel) when a physician orders the tests together as a panel.

    Labs can usually calculate LDL cholesterol based on lipid-panel test results. But what happens if the triglyceride level from the screening lipid panel indicates the need for direct LDL measurement - a test that Medicare does not cover under the CV screening rules? Many labs reflexively conduct a direct-measure LDL when triglycerides exceed certain parameters. The final rule provides direction for direct-measured-LDL coverage (83721, Lipoprotein, direct measurement; direct measurement, LDL cholesterol), when appropriate.

    Key: Medicare says labs and physicians should follow these steps to get paid for direct measure LDL):

  •  Labs must offer physicians the ability to order a lipid panel without the LDL reflex option.
  •  Physicians should order the non-reflex option
  •  Upon viewing lipid panel test results that indicate the need for a direct-measure LDL, the physician can order the test under the diagnostic lipid testing NCD. CMS states, "The NCD for lipid testing includes coverage of direct measurement LDL for patients with hyperglyceridemia."

    Does that mean the patient must return to the ordering physician and the lab must receive a new blood sample? No, according to the final rule. "Laboratories may archive the initial specimen and use it for subsequently ordered medically necessary direct measurement LDL," says CMS.
     
    Physician education can help mitigate Medicare's concern regarding LDL reflex testing. "We offer the lipid panel, which doesn't reflex to direct-measure LDL cholesterol and a lipid panel cascade," Bonifas says. "When physicians order the cascade, they agree that if the panel triglycerides exceed 400 mg/dL, they assign a diagnosis of hyperglyceridemia (272.1) and order a direct-measure LDL."

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