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  1. Alicia Posted 7 Year(s) agoRelated Topics

    What is the correct code to get paid for an A1C done in a primary care physician's office?

  2. SuperCoder Posted 7 Year(s) ago

    The code is based on device used.

    Part B Medicare put out a coverage notice saying you can bill both A1C testing codes, 83036 and 83037, in the doctor’s office. The main difference between the two is that 83037 is for “devices cleared by the FDA for home use.”

    So you should be careful not to use 83037 if your doctor is using a “desk top analyzer” or other device that
    the FDA hasn’t approved for use at home.

  3. SuperCoder Posted 7 Year(s) ago

    Local Medical Review Policy (LMRP) and National Coverage Determinations (NCD) for Glycated Hemoglobin (A1c)Local Medical Review Policy(LMRPs) or National Coverage Determinations (NCDs) dictate the coverage for clinical laboratory tests in regard to medical necessity issues.
    ICD-9 Codes Covered by Medicare
    211.7 Benign neoplasm of islets of Langerhans
    250.00-250.93 Diabetes mellitus and related codes
    251.0 Hypoglycemic coma
    251.1 Other specified hypoglycemia
    251.2 Hypoglycemia, unspecified
    251.3 Post-surgical hypoinsulinemia
    251.4 Abnormal secretion of glucagon
    251.8 Other specified disorders of pancreatic internal secretion
    251.9 Unspecified disorder of pancreatic internal secretion
    258.0-258.9 Polyglandular dysfunction and related disorders
    271.4 Renal glycosuria
    275.0 Disorders of iron metabolism (hemachromatosis)
    577.1 Chronic pancreatitis
    579.3 Other and unspecified post-surgical nonabsorption
    648.00 Diabetes mellitus complicating pregnancy, unspecified episode
    648.03 Diabetes mellitus complicating pregnancy, antipartum complication
    648.04 Diabetes mellitus complicating pregnancy, postpartum complication
    648.80 Abnormal glucose tolerance complicating pregnancy, unspecified episode
    648.83 Abnormal glucose tolerance complicating pregnancy, antipartum complication
    648.84 Abnormal glucose tolerance complicating pregnancy, postpartum complication
    790.2 Abnormal glucose tolerance test
    790.6 Other abnormal blood chemistry (hyperglycemia)
    962.3 Poisoning by insulin and antidiabetic agents
    V12.2 Personal history of endocrine, metabolic, and immunity disorders
    V58.69 Long term current use of other medication

    Frequency of testing considered medically necessary
    Every 3 months to monitor a diabetic patient’s metabolic control
    Every 1-2 months when treatment regimen is altered to improve control
    Every month for diabetic pregnant women
    Patients with uncontrolled type I or II diabetes may be tested more frequently, however, the
    medical record must support such increased testing.
    Billing Medicare Patients for Services Which May Be Denied
    Medicare patients may be billed for services that are clearly not covered. For example,
    routine physicals or screening tests such as total cholesterol are not covered when there is
    no indication that the test is medically necessary. However, when a Medicare carrier is
    likely to deny payment because of medical necessity policy (either as stated in their written
    Medical Review Policy or upon examination of individual claims) the patient must be
    informed and consent to pay for the service before it is performed. Otherwise, the patient
    has no obligation to pay for the test.
    An Advance Beneficiary Notice (ABN), sometimes called a patient waiver form, is used to
    document that the patient is aware that Medicare may not pay for a test or procedure and
    has agreed to pay the provider in the event payment is denied. Each ABN must be specific
    to the service provided and the reason that Medicare may not pay for the service. Blanket
    waivers for all Medicare patients are not allowed.
    Since both LMRPs as well as the new NCD for A1c include frequency limits, an ABN is
    appropriate any time the possibility exists that the frequency of testing may be in excess of
    stated policy. For example, if an A1c test may have been performed by another provider
    less than three months ago for a patient with uncomplicated diabetes, it would be prudent
    to obtain a signed ABN.
    The CPT code modifier, -GA (Waiver of Liability Statement on File), is used to indicate that
    the provider has notified the Medicare patient that the test performed may not be
    reimbursed by Medicare and may be billed to the patient.
    An ABN must: (1) be in writing; (2) be obtained prior to the beneficiary receiving the
    service; (3) clearly identify the particular service; (4) state that the provider believes
    Medicare is likely to deny payment for the service; (5) give the reason(s) that the provider
    believes that Medicare is likely to deny payment for the specific service, and (6) include
    the beneficiary’s signature and date. Routine notices to beneficiaries which do nothing
    more than state that Medicare denial of payment is possible, or that the provider never
    knows whether Medicare will pay for a service, are not considered acceptable evidence of
    advance notice.

    Securing a CLIA Certificate of Waiver
    The Metrika A1cNow is classified as a CLIA Waived Category test by the FDA. A CLIA
    certificate is required any time a clinical laboratory test is performed; however, waived
    category tests require only a CLIA Certificate of Waiver. Certificate of Waiver labs must
    register with Medicare, pay a $150.00 fee every two years and agree to follow
    manufacture’s instructions. No inspections or other CLIA regulations apply.

About this Question

  • Posted by 17153 Alicia, 7 Year(s) ago. There are 3 posts. The latest reply is from SuperCoder.