Wiki WELLNESS LABS: Medicare and Private payers

[lmbennett]

I work for a provider based clinic, and now a Provider based Rural Health Clinic. All of of labs are billed through our Hospital as out patient Place of service. We have had patients come in for Wellness labs: CMP, CBC, Lipid panel, Hba1c for Diabetics, and their labs are being sent to their deductibles instead of being covered. We thought that it was due to the place of service being an outpatient facility instead of in the clinic, but we recently had a billing advisor come. She stated that the place of service should not be the issue for the denial. When we were billing these wellness labs our EMR would ask the hospital coders to add additional dx to cover medical necessity. She thinks it was due to the additional dx, and that we should only be coding Z00.00 or z00.01 or z00129 for wellness labs. This way the labs are not all sent to the patients deductible and are 100% covered. We just sent back a few test claims, but I wanted to see if anyone was having this issue or had any advise. Thoughts?

She also stated to make sure the labs the physicians are ordering are covered under wellness labs, but 83036 for a1c should be covered for diabetes patients or prediabetes, correct?
Thanks in advance!

 

[thomas7331]

Each payer, and even each plan within any given payer, is going to have its own list of labs that is covers as part of the preventive care benefit. So whether or not these are covered is really going to vary a lot from patient to patient.

For Medicare, here's a good tool, link below, that lists all of the preventive care services that it covers - if you select any of the items, it will give you the coding requirements needed to indicate that it's preventive when you bill. In some cases, that involves billing the Medicare 'G' code instead of the CPT code.

Lipids are included under 'Cardiovascular Disease', but I don't see that the a1c test is included for Medicare as one of the 'Diabetes Screening' services. I don't believe Medicare will cover CMP or CBC as a wellness test.

Preventive Services Chart