(Reproduced by permission from MedicareFocus, August, 1998, pg. 17 - 21.)
Description
A blood test which measures the level of sugar and is utilized to determine the response to current therapy, stabilization, and management of hyper-or hypoglycemic patients.
Type of Bill
12X, 13X, 14X, 22X, 23X, 71X, 74X, 75X,
Revenue Codes
30X, 31X
Indications and Limitations of Coverage and/or Medical Necessity
Medicare does not pay for routine screening tests. ICD-9-CM code V82.9, (special screening of other conditions, unspecified condition), or comparable narratives should be used to indicate screening tests performed in the absence of a specific sign, symptom or complaint. Use of V82.9 or comparable narrative will result in the denial of claims as non covered screening services.
Blood glucose testing is performed to:
· |
Diagnose hypoglycemia |
· |
Diagnose hyperglycemia |
· |
Aid in the management of diabetes mellitus |
HCPCS Codes
82947 |
Glucose, quantitative |
82948 |
Blood, reagent strip |
ICD-9 Codes That Support Medical Necessity
Diagnosis Definition
Malignant Neoplasms of Digestive Organs and Peritoneum
157.4
Malignant Neoplasm of Other and Unspecified Sites
194.0
198.7
Benign Neoplasms
211.7
Diseases of Other Endocrine Glands
250.00-250.93
251.0
251.1
251.2
251.3
253.0
Other Metabolic and Immunity Disorders
276.0
276.1
276.5
276.7
276.8
276.9
277.7
Revised per Medicare Focus December, 2001
Other Disorders of the Central Nervous Systems
345.10-345.11
348.3
Other Disorders of the Peripheral Nervous Systems
357.9
Revised per Medicare Focus April, 2001
Disorders of the Eye and Adnexa
368.8
Other Diseases of Digestive System
570-571.9
577.0
577.1
Disease of Male Genital Organs
607.84
Revised per Medicare Focus April, 2001
Complications Mainly Related to Pregnancy
648.0-648.04
648.8-648.84
Symptoms
780.09
Revised per Medicare Focus April, 2001
780.2
780.4
780.71 Revised per Medicare Focus September, 2001
780.79 Revised per Medicare Focus September, 2001
783.21 Revised per Medicare Focus December, 2000
783.5
788.41-788.43
Non Specific Abnormal Findings
790.2
790.6
791.5
791.6
Persons Encountering Health Services in Circumstances Related to Reproduction and Development
V22.0-V22.2
V23.0-V23.7
Persons Encountering Health Services for Specific Procedures and Aftercare
V58.69
V67.51
Drugs, Medicinal and Biological Substances Causing Adverse Effects in Therapeutic Use
E932.0
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.
Title XVIII of the Social Security Act, section 1862(a)(7). This section excludes routine
physical examinations.
Reasons For Denial
Laboratory tests that are performed for screening purposes are statutorily excluded from coverage by Medicare. Routine screening and prophylactic testing are not allowed for payment purposes in the Medicare program. Only those services which directly relate to disease, injury or malfunctioning body parts are covered by Medicare. Excessive frequency of testing will be denied as not medically necessary.
Non-Covered ICD-9 Diagnosis Codes
Any ICD-9-CM code not listed in "ICD-9-CM Codes That Support Medical Necessity" above.
Sources of Information
Harrison's Principles of Internal Medicine, 13th Edition
1998 Physicians' Current Procedural Terminology, CPT '98, American Medical Association
Diagnostic Tests Handbook, Springhouse Corporation 1987.
CMD Clinical Laboratory Workgroup
Other Intermediary Policies
Coding Guides
· |
Any claim for a test listed in "HCPCS Codes" above must be submitted with an ICD-9-CM diagnosis code. |
· |
ICD-9-CM code V82.9, (special screening of other conditions, unspecified condition), or comparable narratives should be used to indicate screening tests performed in the absence of a specific sign, symptom, or complaint. Use of V82.9, or comparable narrative will result in the denial of claims as non-covered screening services. |
· |
All ICD-9 diagnosis codes must be coded to the highest level of specificity. |
Reconsiderations and Appeals - Claims resubmitted with a different diagnosis code must include medical documentation to justify the diagnosis code change. Submission with diagnoses other than those listed as "Covered Codes" will be individually reviewed by this Intermediary for medical necessity.
Documentation Requirements
Documentation supporting the medical necessity of these tests, such as ICD-9 diagnosis codes or comparable narrative must be submitted on the claims. Failure to do so may result in rejection or denial of claim(s). The ordering physician should retain in the patient's medical record, history and physical examination notes documenting evaluation and management of one of the Medicare covered conditions/diagnoses, with relevant clinical signs/symptoms or abnormal laboratory test results, appropriate to one of the covered indications. The patient's clinical record should further indicate changes/alterations in medications prescribed for the treatment of the patient's condition. There must be an attending/treating physician's order for each test documented in the patient's medical/clinical record. Documentation must be submitted to Medicare upon request.
ICD-9-CM diagnosis codes are required on claim. Medical records must clearly document the medical necessity for the test and the frequency of the test.
If documentation is requested for review, submit the following:
· |
History and Physical |
· |
Physician orders/progress notes |
· |
Diagnosis/reason for test |
· |
Test results |
· |
Itemization of charges |
Comments
Reviewing results of laboratory tests, phoning results to patients, filing such results, and such activities as obtaining, reviewing, and analyzing the appropriate diagnostic tests, etc., are services which are covered by the program, and payment for these services is included in the payment for the evaluation and management (E&M) services to the patient.
Blood glucose testing is not eligible for coverage when performed for:
· |
Screening purposes in asymptomatic individuals |
· |
Individuals without signs or symptoms of hypoglycemia or hyperglycemia without diagnoses related to diabetes mellitus |
· |
a diagnostic condition unrelated to hypo or hyperglycemia or diabetes mellitus |
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.
This policy is a revision of and supersedes previous Part A Policy published July 15, 1996.
Start Date of Comment Period: |
April 3, 1996 |
Start Date of Notice Period: |
June 12, 1996 |
Original Effective Date: |
July 15, 1996 |
Revised Effective Date: |
August 1998 |
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 other Intermediaries and other Intermediary policies.