Wiki 83036 A1c denials

[01085585]

We are a family practice medical facility and we all of a SUDDEN received denials for 83036 which is checking the A1c. Has anyone else had a similar problem. The denials date back to 06,28.2011 that is when the denials started. Most of these have been 3 months or more from the last time 83036 was just to check the a1c. Any suggestions?

 

[encomma-watson]

Dont forget that it is all about the insurance companies. if you are getting denials on 83036 try 83037-qw. Hey I just thought of something, are you adding the QW modifier to your 83036, if not add it and you might just get paid.

 

[01085585]

Hey- yes we are appending the QW to the 83036

 

[kvangoor]

We are getting these denials also. We bill the 83036 with a qw. I did some research and this is only payable every 3 months for most patients. Our schedulers have been making appts. 3 months out to the day so we changed that. I believe the documentation is in the LCD for CLIA lab tests.

 

[kvangoor]

By the way, it seems only to be an issue with Medicare.

 

[01085585]

yES Medicare is only one.. what are you doing different to fix this?

 

[kvangoor]

Scheduling patients for these services greater than 3 months from the last.

 

[01085585]

I mean are you refiling any of them?

 

[kvangoor]

We tried to appeal them but they got denied. Let me know if you have any luck getting yours paid!

 

[kvangoor]

I wanted to let you know that we have had some luck appealing these. Patients that have "uncontrolled" dm are allowed to have their A1C's more freq. We have looked at some of these records and got some of these paid by appealing with notes!

 

[abranch13]

I have also been told by Medicare they are having an issue with these, there are processing as 3 calendar months but the NCD reads 3 months, from what they have told me they are working with CMS on a resolution....last I checked they have still not resolved.

 

[Tricia13]

Tda, ba, cpc

Just and FYI if this is pertinent, per the National Coverage Determination, effective 8/1/2011, 83036 will no longer be covered under Medicare if performed more than 4 times per calendar year.

 

[01085585]

thank you so mucg for that info

 

[Lorisvg]

You are suddenly starting to get denials because patients are getting to the end of 12 month periods.
Medicare will pay for 4 HgbA1c's in a 12 month period - not a calendar year.
If the patient's DM is uncontrolled, or they have had changes to their diabetes medications you should appeal it with office notes.

 

[01085585]

How do you know it is a 12 month period and not a calendar year? what is the difference? Thank you

 

[jtraversa]

Our clinic has contacted Medicare because ours were being denied even though we had a GA modifier on them. They stated that there was something wrong with their system and were not able to tell us if we would have to resubmit - or if they would automatically reprocess them when it was fixed. Just check with Medicare.