Pathology/Lab Coding Alert

Think you can't bill Medicare for 2 screenings per year? Think again Fact: The United States spends $100 billion per year on direct and indirect health costs related to diabetes. With lab testing for diagnosis and monitoring a significant part of that expense, you can't afford any diabetes coding mistakes. Get the truth behind six myths that could be eating your diabetes reimbursement from Sheri Bernard, CPC, CPC-H, CPC-P, vice president of member relations with the American Academy of Professional Coders. Myth 1: You can bill Medicare for only one diabetes screening per year. Fact: Medicare pays for two diabetes screening tests per year if the patient has significant risk factors such as pre-diabetes or dysmetabolic syndrome X (277.7), Bernard says. You should be seeing this diagnosis code a lot because there are approximately 41 million pre-diabetics in this country. You can't use 277.7 unless the doctor documents three of the following, Bernard says: abdominal obesity hypertension fasting glucose of 110 or higher high triglycerides in cholesterol (bad cholesterol) low HDL in cholesterol (good cholesterol). Don-t: You shouldn't assign 277.7 as the diagnosis automatically if you see three or more of these factors in the record. Ask the doctor first. Also, don't use the screening code if the patient has had a diagnosis of diabetes in the past, or if the patient has acute symptoms and the screening isn't -routine.- When billing screening tests 82947 (Glucose; quantitative, blood [except reagent strip]), 82948 (Glucose; blood, reagent strip) or 82950 (Glucose; post glucose dose [includes glucose]), make sure to attach modifier QW (CLIA waived test) for labs operating with a certificate of waiver under the Clinical Laboratory Improvement Amendments. Also, don't forget to append modifier TS (Follow-up service) if the test is a follow-up for a pre-diabetic patient. The absence of modifier TS is a big reason carriers deny twice-yearly screenings for 277.7 patients. Also: Make sure to bill 36415 (Collection of venous blood by venipuncture) and include diagnosis code V77.1 (Special screening for diabetes mellitus). Watch for Complications and Medications Myth 2: If the physician orders lab tests because of a diabetes complication, you should always sequence the diabetes diagnosis code (250.xx) first. Fact: There are a few exceptions to that rule, Bernard says. You should report the diabetes code secondarily only in case of: insulin pump malfunction heart problems cerebrovascular problems decubitus ulcer. Myth 3: If the patient is taking insulin, you need to list V58.67 (Long-term [current] use of insulin) for continuing use only. Fact: Use V58.67 only when a type II diabetes patient is taking insulin long-term. You don't need this V code for type I diabetes diagnosis codes because those patients are always taking insulin long-term, Bernard [...]