(Reproduced by permission from Medicare Focus, May 2000, Web Edition)
Policy Number: |
A00-16 Revised |
Description
The contemporary management of diabetes mellitus is based principally on frequent determinations of capillary blood glucose levels. Patients with diabetes mellitus obtain blood by the finger prick method and measure the glucose with a reagent strip or meter. The monitoring of urinary glucose is not sufficiently precise for optimal control of diabetes.
Glycated hemoglobin is used to assess long-term glucose control in diabetes, especially in insulin-dependent diabetics whose glucose levels are labile and in whom blood and urine glucose measurements show significantly daily variances. Glycated hemoglobin assesses diabetic control over a longer period of time.
Type of Bill
12X, 13X, 14X, 22X, 23X, 24X, 28X, 71X, 72X, 73X, 83X, 85X
Revenue Codes
30X
Indications and Limitations of Coverage and/or Medical Necessity
Indications
This test is performed to assess control of diabetes mellitus. Since glycosylation occurs at a constant rate during the 120-day life of an erythrocyte, glycosylated hemoglobin levels reflect the average blood glucose level during the preceding two to three months, and therefore can be used to evaluate the long-term effectiveness of diabetes therapy.
As effective therapy brings diabetes under control, glycosylated hemoglobin levels approach the normal range.
Current medical literature and accepted medical practice suggest that it is generally not medically necessary for the test to be performed more frequently than four times per year.
Limitations
Screening tests are defined as those tests done in the course of an annual physical examination or as part of a routine physical checkup, without signs, symptoms or the presence of an illness. The test covered by this local medical review policy when done as a screening test would not be a covered Medicare benefit.
CPT/HCPCS Code
83036 |
Hemoglobin; glycated |
ICD-9-CM Codes That Support Medical Necessity
One of the following covered ICD-9-CM diagnosis codes must be linked to the appropriate procedure.
The correct use of an ICD-9-CM code listed below does not guarantee coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this policy.
Diagnosis Definition
Diseases of Other Endocrine Glands
250.00 - 250.03
250.10 - 250.13
250.20 - 250.23
250.30 - 250.33
250.40 - 250.43
250.50 - 250.53
250.60 - 250.63
250.70 - 250.73
250.83 - 250.93
251.8
Complications Mainly Related to Pregnancy
648.00 - 648.04
648.80 - 648.84
Nonspecific Abnormal Findings
790.2
790.6
HCPCS Section and Benefit Category
Pathology and Laboratory
HCFA National Coverage Policy
Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be reasonable and medically necessary, i.e., reasonable and necessary are those tests used in the diagnosis and management of illness or injury or to improve the function of a malformed body part.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Reasons for Denial
Claims not meeting the coverage criteria as stated in the Indications section of this policy will be denied.
Services will always be denied which are considered:
· |
Experimental; or |
· |
Cosmetic; or |
· |
Routine screening; or |
· |
A program exclusion; or |
· |
Never medically necessary; or |
· |
Otherwise not covered |
Non-covered ICD-9-CM Diagnosis Codes
Any code not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this policy.
Codes that are never covered:
V70.0-V70.9
V82.9
Sources of Information
· |
1998 CPT Book, American Medical Association |
· |
Laboratory and Diagnostic Tests. 5th ed. Lippincott, 1996 |
· |
Henry J.B., M.D. Clinical Diagnosis and Management by Laboratory Methods. 19th ed. W.B. Saunders, 1996. |
· |
Other Carriers' Policies |
· |
Isselbacher K.J., et al. Harrison’s Principles of Internal Medicine. 13th ed. McGraw-Hill, 1994 |
· |
Standards of Medical Care for Patients with Diabetes Mellitus. Diabetes Care 22 (Suppl.1). 1999;532-41. |
· |
Kilpatrick E.S. Problems In the Assessment of Glycaemic Control In Diabetes Mellitus. Diabet Med 1997 Oct;14 (10): 819-31. |
· |
Goldstein D.E., Little R.R. Monitoring Glycemia In Diabetes. Short-term Assessment. Endocrinol Metab Clin North Am 1997 Sep; 26 (3): 475-86. |
· |
Goldstein D.E., Little R.R., Wiedmeyer H.M., England J.D., Rohlfing C.L., Wilke A.L., Is Glycohemoglobin Testing Useful In Diabetes Mellitus? Lessons From the Diabetes Control and Complications Trial. Clin Chem 1994 Aug; 40 (8): 1637-40. |
Coding Guidelines
It is anticipated that this test would not be performed as follow up (repeated) until sufficient time has elapsed after changes in diabetic regimen are made.
Report the principal diagnosis (Form Locator 67) to your highest degree of certainty. Secondary diagnosis codes (Form Locator 68-75) should include the patient's presenting symptoms and any other medical conditions that may effect the patient’s care (Refer to the May 1999 issue of Medicare Focus).
Reconsiderations and Appeals - Claims resubmitted with a different diagnosis code must include medical record documentation to justify the diagnosis code change. Submission with diagnoses other than those listed in the "ICD-9-CM Codes That Support Medical Necessity" section of this policy, will be individually reviewed by this Intermediary for medical necessity.
Documentation Requirements
Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary.
All coverage criteria must be documented in the patient's medical record and made available to Medicare upon request. This information should be generally submitted on reconsideration only (or with the claim if the services are unusual or if denial is anticipated).
ICD-9-CM diagnosis codes are required on claim.
If documentation is requested for review, submit the following:
· |
History and Physical |
· |
Physician orders/progress notes |
· |
Nurses notes |
· |
Medication sheet indicating the name of drug, the dosage and route administered |
· |
Diagnosis/reason for drug |
· |
Itemization of charges |
Comments
This Local Medical Review Policy replaces any other previously published policy and/or items related to glycated hemoglobin.
This policy should be interpreted to incorporate future changes in the ICD-9-CM or CPT/HCPCS coding systems such that its original intent and scope will not be substantively changed.
CPT only © 1999 American Medical Association. All Rights Reserved.
All International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes and descriptions are copyright © 1998 Medicode, Inc.
Original |
Revised | |
Start Date of Comment Period |
April 16, 1996 |
January 25, 2000 |
Start Date of Notice Period |
October 1996 |
May 1, 2000 |
Original Effective Date |
November 1, 1996 | |
Revised Effective Date |
June 1, 1998 |
June 1, 2000 |
Approval
This policy does not reflect the sole opinion of the Intermediary/Medical Director. Although the final decision rests with the Intermediary, this policy was developed in conjunction with the other Intermediaries and other Intermediary policies.