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80061 and 82962

Tammy Posted Mon 15th of April, 2013 19:12:34 PM

These codes have been denied twice after physican reviewed the LCD. the first dx was V70.0 80061 changed to V77.91 and 82962 to V77.1. My questions- Does MCR typically pay for screening blood tests if dx is medically necessary?

SuperCoder Answered Tue 16th of April, 2013 16:59:49 PM

If your patient presents for a quantitative blood glucose test to screen for diabetes, the chart indicates that you'll report 82947 with diagnosis code V77.1, and you should not charge the patient coinsurance or deductible. Medicare covers this visit twice a year for pre-diabetic patients and once a year for patients with certain diabetes risk factors.

To access the chart, visit the CMS Web site at

Coverage depends on how long ago the patient received the lipid panel (80061, Lipid panel). In order to meet Medicare's guidelines, the panel must have occurred at least five years ago.Do this: Check how long ago the patient had the lipid panel. If it's less than five years, let him know that Medicare won't pay for the test.

Follow Medicare Rules for Blood Glucose Monitoring

Glucose monitoring involves frequent blood tests with an FDA-approved device for home use. Because the purpose of monitoring is to manage insulin therapy (shots, medication and diet), testing often occurs several times a day, far exceeding the previously mentioned four times per year. Medicare Part B may pay for a glucose monitoring device and related supplies for home use under the durable medical equipment benefit. However, a hospital or skilled nursing facility (SNF) is not considered a home under this benefit.

Because of increased claims for glucose monitoring with home-use devices in the hospital, SNF and home health agency (HHA) settings using 82962, Medicare issued a program memorandum regarding coverage for this service (AB-00-108, dated Dec. 1, 2000). The memo states, If home-use glucose monitoring devices are used in the hospital and nursing home settings, a glucose monitoring service must be performed in accordance with laboratory coverage criteria to qualify for separate payment under the Medicare laboratory benefit.

To qualify for coverage in a facility, the home-use glucose monitoring device must be ordered by the physician, and administered by a healthcare provider registered under CLIA with at least a certificate of waiver, says Laurie Castillo, MA, CPC, CPC-H,
CCS-P, member of the National Advisory Board of the American Academy of Professional Coders. Also, the results of the test must be reported promptly to the ordering physician and used to instruct continuation or modification of patient care (including the order for another laboratory service), Castillo says. Standing orders are not generally acceptable documentation for coverage of a laboratory service.

Having met those criteria for coverage, billing for the service will depend on the patients Medicare coverage and the type of facility, Castillo says. For patients eligible for services under Medicare Part B but not covered by Part A, different billing and reimbursement arrangements are in effect for hospitals, SNFs and HHAs.

The 82962 glucose monitoring service for a hospital patient is submitted to the intermediary using UB-92 (HCFA 1450 form), type of bill (TOB) 12x, revenue code 30x, and is paid under the clinical laboratory fee schedule, Castillo says. In an SNF, if the patient is in a certified bed, the procedure is billed on the UB-92, TOB 22x, with revenue code 30x for reimbursement at reasonable cost, which must be reflected in the laboratory cost center. However, if the patient is in a non-certified bed, the service is billed on the UB-92, TOB 23x, revenue code 30x, and reimbursed under the clinical laboratory fee schedule, Castillo says.

Often, patients in an HHA will self-administer the glucose monitoring, even if an employee has to supervise and assist the patient, Castillo says. This service is not separately billable as a laboratory test but is considered encompassed in the home health service. However, if the lab test meets the laboratory coverage criteria outlined above, it is separately billable for a patient covered under Medicare Part B but not Part A. The HHA must have a supplier number, and submit HCFA form 1500 to the Medicare carrier, Castillo says.

Under any of these arrangements involving glucose monitoring of a diabetic patient, the physician may also order a separate quantitative blood glucose test from venous blood. This procedure is separately reported using the appropriate code, such as 82947.

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