Pathology/Lab Coding Alert

"V" codes show medical necessity for diabetes, heart disease Now your lab can get paid for diabetes and cardio-vascular (CV) disease screening by following Medicare's new rules. You'll need to link the proper ICD-9 and CPT codes and only report the tests as often as Medicare allows - otherwise you'll need an Advance Beneficiary Notice (ABN) for the service.

Medicare clarifies coding issues and finalizes criteria for screening tests physicians order beginning Jan. 1. You can find the new rules in the 2005 Physician Fee Schedule, published in the Nov. 15, 2004 Federal Register and available on the Internet at http://www.access.gpo.gov/su_docs/fedreg/a041115c.html. No New "G" Codes for Screening Unlike many other screening tests reported to Medicare, you won't use temporary "G" codes to bill screening for diabetes and CV disease. "Labs currently use HCPCS Level II codes to report most screening tests to Medicare, even when a CPT code accurately describes the same test," says Mary Jo Bonifas, MT (ASCP), manager of laboratory services at United Clinical Laboratories in Dubuque, Iowa. That's because Medicare in many cases requires a two-tiered coding system, instructing labs to report tests such as prostate specific antigen (PSA) with a "G" code for screening (G0103, Prostate cancer screening; prostate specific antigen test [PSA], total) and a CPT code for the same test for diagnosis (84153, Prostate specific antigen [PSA]; total). You also currently distinguish between CPT codes and HCPCS Level II codes ("G" or "P") for diagnostic vs. screening Pap tests.

But CMS says it's working toward phasing out "G" codes, thanks in part to the Health Insurance Portability and Accountability Act (HIPAA) standardization requirements for code sets. So for diabetes and CV disease screening, Medicare instructs labs to report specific screening ICD-9 codes linked to the approved lab-test CPT codes to indicate a screening test. Note that using the CPT code means that Medicare will pay for the screening lab test at the same rate as a diagnostic lab test ordered with the same code - the rate designated on the Clinical Laboratory Fee Schedule. "V" Codes Show Screening Medical Necessity Instead of "G" procedure codes, you should use a CPT code plus "V" diagnosis codes to document screening diabetes and CV disease tests. "Medicare wants to see a screening diagnosis code so that the claim falls under the screening coverage rules," says Elissa Passiment, EdM, CLS (NCA), executive director of the American Society for Clinical Laboratory Science (SSCLS).

Do this for diabetes: Use V77.1 (Special screening for diabetes mellitus) to report a screening test for a patient at risk for diabetes.

Medicare says that it will consider patients with at least one of the following conditions to be "at risk" for developing diabetes:

1. Hypertension
2. Dyslipidemia
3. Obesity (body mass index [BMI] [...]