Alicia Posted 7 Year(s) ago
What is the correct code to get paid for an A1C done in a primary care physician's office?
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.
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
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.
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