Part B Insider (Multispecialty) Coding Alert

Published on Fri Jul 14, 2006 PDF

You can bill for more than 4 tests a year if the diagnosis warrants

Watch out: If you bill 83036 (Hemoglobin; glycosylated [A1C]) or 83037 (Hemoglobin; glycosylated [A1C] by device cleared by FDA for home use) more often than covered based on the National Coverage Determination or other payor guidelines, you won't get paid. Carriers base the frequency rules on the patient's diagnosis, which means you'll have to be familiar with the ICD-9 codes.

A fifth digit is the key to success: "Hemoglobin A1C is the standard for monitoring type 1 and type 2 diabetes," says Nathaniel Clark, MD, MS, RD, of the American Diabetes Association. To get paid for A1C testing, you must also report whether the patient has long-term, stable glycemic control. The diabetes code must include a fifth digit, which specifies type I or type II diabetes and whether the diabetes is controlled or uncontrolled.

The proper procedure: Use the following fifth-digit subclassification with category 250 (Diabetes mellitus):

0---type II or unspecified type, not stated as uncontrolled
1---type I (juvenile type), not stated as uncontrolled
2---type II or unspecified type, uncontrolled
3--type I (juvenile type), uncontrolled

Select the appropriate diabetes four-digit code based on the complications, if any, and then assign the appropriate fifth digit to indicate diabetes type and control.

Example: If the physician reports uncontrolled diabetes and you report the appropriate fifth digit (2 or 3), you can expect to get paid for A1C testing more frequently than four times a year. Your documentation must show lack of glycemic control to demonstrate medical necessity for more frequent testing.

Don't be fooled: Insulin use doesn't always mean type I diabetes. You can report 0 or 2 as the fifth digit even if the patient requires insulin, according to ICD-9 instructions. You should additionally report V58.67 (Long-term [current] use of insulin) in those cases.