Medicare payment for lab cpt code 83036 - important points to consider

Medicare Payment for Clinical Laboratory Services

Before Medicare pays for any test or diagnostic service, two basic criteria must be met:

(1) the service must be covered by Medicare (e.g., certain procedures such as routine screening tests are not covered) and 

(2) the service must be medically necessary or indicated.

Once these two criteria are met, Medicare pays for most clinical laboratory tests based on the Laboratory Fee Schedule. Each carrier publishes a unique laboratory fee schedule and  adjusts payment levels annually on January 1st based on Congressional budget recommendation.

Medicare payment for clinical laboratory tests is always the lesser of the fee schedule amount or the actual amount billed. The provider must accept the Medicare reimbursement as payment in full for a laboratory test. 

Medicare patients may NOT be billed for any additional amounts. Tests must be billed directly to Medicare by the laboratory or physician performing the test. If an outside laboratory performs a test on a referral from a physician, only the reference laboratory may legally bill Medicare for the procedure.

Procedure (CPT) Codes and Modifiers 

The CPT codes for Glycated Hemogobin (A1c) determinations are:

83036 Hemoglobin; glycated (A1c)

83036QW Hemoglobin; glycated (A1c) using CLIA waived method

Medicare reimbursement for CPT codes 83036 and 83036QW is $13.42 in all states except:

Idaho: $9.66 Maryland: $12.66 Oklahoma: $11.95

Rhode Island: $12.09 South Dakota: $12.86 Wyoming: $10.49

Diagnosis (ICD-9) Codes

An appropriate diagnosis (ICD-9) code (or narrative description) must be indicated for each service or supply billed under Medicare Part B. ICD-9-CM is an acronym for International Classification of Diseases, 9th Revision, Clinical Modification.

When a patient presents with an undiagnosed illness, the ICD-9 code is determined by the "signs and symptoms" present. Symptoms are defined as what the patient tells the physician. Signs are what the physician observes as part of his examination of the patient. 

Definitive ICD-9 codes should only be assigned and recorded in the medical record after a diagnosis is clearly determined. Terms such as "rule out", "probable", and "suspected" should NOT be used since they can not be coded as such and may be interpreted as a firm diagnosis by a third party payer.

New Jersey Claim Review on HCPC 83036 and 36415

New Jersey Service Wide Glycosylated Hemoglobin Lab Test and Venipuncture Probe Results

New Jersey Claim Review on HCPC 83036 and 36415

In an effort to safeguard the Medicare Trust Fund by lowering the Comprehensive Error Rate Testing (CERT) paid claims error rate, Highmark Medicare Services’ Medical Review Department performs reviews and provides education based on data analysis performed to identify problem areas. The CERT program is the driver of this data analysis. 

The Centers for Medicare and Medicaid Services (CMS) and Highmark Medicare Services uses the information from the CERT error rate findings to determine the underlying reasons for claim errors and develops appropriate action plans to improve compliance in payment, claims processing, and provider billing practices.

Recent CERT data analysis indicated that there were claim errors in New Jersey for procedure code 83036 for Glycated Hemoglobin lab test and 36415 Venipuncture. As a result of this data analysis, Highmark Medicare Services’ Medical Review Department conducted a widespread post payment review in New Jersey on procedure code 83036 and 36415.

Our findings indicated that 53% of the claims sampled were missing documentation. The majority of the reductions/denials were based on the following:

• Physician order/referral information was missing from supporting documentation

• Submitted documentation did not support the billed diagnosis

• Requested documentation was not received in a timely manner

Please refer to the following publication for information on billing procedure codes 83036 and 36415:

• Medicare National Coverage Determination (NCD) 190.21 Glycated Hemoglobin / Glycated Protein As a result of these findings, and to assist in the reduction of the overall claims payment error rate, a prepayment review will be implemented on procedure codes 83036 and 36415, for New Jersey providers. Medical records will be requested to verify that services billed were rendered, medically necessary, adequately documented, and billed appropriately to the Medicare program. 

Please, do not send in documentation until requested by the Additional Documentation Request (ADR) process. If the requested medical record documentation is not made available upon request to support services billed, the service may be denied.

GLYCOSYLATED HEMOGLOBIN (CPT 83036, 83037)

ICD-10 Description           ICD-10    ICD-9

Abnormal Finding Of Blood Chemistry, Unspecified R79.9 790.6

Other Abnormal Glucose R73.09 790.29

Other Long-Term (Current) Drug Therapy Z79.899 V58.69

Coding Glycosylated Hemoglobin (A1c) and Hemoglobin Variants by HPLC

CPT code 83036 (Hemoglobin; glycosylated (A1c)) is typically used to report HbA1c independent of the method used when a single quantitative result is obtained. However, there is currently no analyte specific code for reporting HbA1c when a hemoglobin variant or HbF is present. 

It is important to identify the presence of a hemoglobin variant in a sample to be tested for HbA1c  since the variant may have decreased red cell survival, increase turnover or reduced expression which may affect the HbA1c value. The presence of HbF can compromise HbA1c results by immunoassay methods providing misleading HbA1c results to the physician.

When no analyte-specific code exists, the most similar code or a code describing the method employed may be reported. In this case, since the method is ion-exchange HPLC, the most appropriate code would be:

83021 Hemoglobin, fractionation and quantitation; chromatography (A2c, Sc, Cc, or Fc) Even though glycosylated hemoglobin A1c is also measured, it would not be appropriate to list

83036 as well since the above code includes tentative identification of the hemoglobin variant (if present) and the detection of the presence of increased HbF levels.

Since the Medicare reimbursement for CPT code 83021 is more than for 83036, there is always a small risk that a payer might consider the choice of 83021 over 83036 to be upcoding in order to achieve a higher reimbursement. Consequently, each provider must exercise their own judgment in choosing how to code glycosylated hemoglobin variants.

When performing glycosylated hemoglobin variants by ion-exchange HPLC, the following rules apply:

1. The test should be described as glycosylated hemoglobin in the presence of Hb variants or HbF to differentiate the test from total glycosylated hemoglobin (A1c). If both tests are offered, both should be listed on the lab requisition.

For example:

* Hemoglobin, glycosylated (A1c) (CPT code 83036)

* Glycosylated hemoglobin in the presence of Hb variants or HbF (CPT code 83021)

2. If Hemoglobin A1c alone is ordered, CPT code 83036 should be used to report the test even if the A1c is determined by ion-exchange HPLC. This code is specific for measurement of total Hb A1c by any method including HPLC.

3. There should be a reasonable expectation, for medically necessity, that the patient have a hemoglobin variant or elevated HbF for the test to be covered by Medicare and other payers. It is generally medically necessary to perform this assay only one time to confirm the absence orpresence of Hb variants ior ncreased levels of HbF.. Subsequent monitoring of A1c by ionexchange HPLC should be reported using CPT code 83036 since this is the only medically
necessary analyte.

Provider Action Needed

This article is based on Change Request (CR) 5987 which alerts clinical laboratories that, effective for tests furnished on or after April 1, 2008, the MMSCHIP Extension Act of 2007 sets payment for code 83037 and 83037QW (Hemoglobin; glycosylated (A1c) by device) by crosswalking it to be the same as 83036 (glycosylated (A1c)). Make certain your billing staffs are aware of this change.

Background

The MMSCHIP Extension Act of 2007 passed in December 2007 and included Section 113. Section 113 of the legislation set the price for any diagnostic test for HbA1C that is labeled by the Food and Drug Administration (FDA) for home use equal to the payment rate for a glycated hemoglobin test (identified as of October 1, 2007, by Healthcare Common Procedure Coding System (HCPCS) code 83036 (and any succeeding codes)). The legislation is effective for tests furnished on or after April 1, 2008.

• For Calendar Year (CY) 2006, the Current Procedural Terminology (CPT) established new code 83037 Hemoglobin; gycosylated (A1C) by device cleared by the FDA for home use. CPT code 83036, glycosylated (A1c), already existed and was priced at $13.56 on the clinical laboratory fee schedule.

• For calendar year 2006, CMS determined that code 83037 should be paid via carrier gap filling.

• For calendar year 2007, CMS set the payment for code 83037 by crosswalking it to code 82985 (Glycated protein).

• For tests furnished on or after April 1, 2008, the payment for 83037 or 83037QW will be the same as the payment on the clinical laboratory fee schedule for 83036.

Your Medicare contractor will adjust claims for services on or after April 1, 2008, processed prior to implementation of this change if you bring such claims to the contractor’s attention. 

CPT Codes (current procedural terminology codes)

83037 Hemoglobin; glycosylated (A1c) by device cleared by FDA for home use.

A1CNow+ is approved for use with either a capillary or venous blood specimen.1

36416 Collection of capillary blood specimen (e.g., finger, heel, ear stick).

36415 Collection of venous blood by venipuncture.

Note 1: CPT code 83037 may be billed when an A1c test is performed in a provider’s office using a device cleared by the FDA for home use. CPT code 83037 is not intended to report an A1c test result that is obtained in a patient’s home by the patient or family.2

Note 2: The QW modifier should be used when coding for Medicare and Medicaid beneficiaries. The QW modifier (83037QW) indicates that the test and laboratory have received a CLIA1 Certificate of Waiver. A1CNow+ has been categorized as a waived test under CLIA.3 

Note 3: CPT code 83037 became available in 2006 and most insurers utilize this new code. Other insurers continue to use 83036. Check with local insurers to confirm the appropriate CPT billing code. 

TESTS GRANTED WAIVED STATUS UNDER CLIA

CPT CODE(S)      TEST NAME     MANUFACTURER     USE

83036QW,

1. Wako APOLOWAKO Analyzer (Whole Blood)

Wako Chemicals USA, Inc.

Measures total cholesterol, hemoglobin A1c, glucose, and triglycerides in whole blood

83036QW

1. Axis-Shield Afinion AS100 Analyzer

Axis-Shield Poc 

Measures the percent concentration of hemoglobin A1c in blood, which is used in monitoring the long-term care of people with diabetes

83036QW  

3. Bayer AICNow+ Professional Use 

Bayer Healthcare, LLC 

Measures the percent concentration of hemoglobin A1c in blood, which is used in monitoring the long-term care of people with diabetes

CPT Code     Description

83036 Hemoglobin; glycated