Question

the patient underwent a blood glucose test, and the provider documented type 2 diabetes mellituz in the patient record. the codee assigned a cpt code to blood glucose test and a icd 10 cm code to typr 2 diabetes mellitus the health insurance company reviwed the submitted claim and determined that support of medical necessity was evident

should tge insurance company reimburse the providee for this encounter? and why or why not?

Answer 1

Ans) Reimbursement and Coding for Prediabetes Screening:

- Medicare recommends and provides coverage for diabetes screening tests through Part B Preventive Services for beneficiaries at risk for diabetes or those diagnosed with prediabetes.

- When filing claims to Medicare for diabetes screening tests, the following Healthcare Common Procedure Coding System (HCPCS) codes, Current Procedural Terminology (CPT) codes, and diagnosis codes must be used to ensure proper reimbursement.

Table 1: HCPCS/CPT Codes and Descriptors

HCPCS/CPT Codes Code Descriptors

82947 Glucose; quantitative, blood (except reagent strip)

82950 Glucose; post glucose dose (includes glucose)

82951 Glucose Tolerance Test (GTT); three specimens (includes glucose)

83036 Hemoglobin A1C

Table 2: Diagnosis Code and Descriptor

Criteria Modifier Diagnosis Code* Code Descriptor

DOES NOT MEET None V77.1 To indicate that the purpose of the test(s) is diabetes screening for a beneficiary who does not meet the *definition of prediabetes. The screening diagnosis code V77.1 is required in the header diagnosis section of the claim.

MEET -TS V77.1 To indicate that the purpose of the test(s) is diabetes screening for a beneficiary who meets the *definition of prediabetes. The screening diagnosis code V77.1 is required in the header diagnosis section of the claim and the modifier “TS” (follow-up service) is to be reported on the line item.

- Center's for Medicare and Medicaid Services (CMS) monitors the use of its preventive and screening benefits. By correctly coding for diabetes screening and other benefits, providers can help CMS more accurately track the use of these important services and identify opportunities for improvement. When submitting a claim for a diabetes screening test, it is important to use diagnosis code V77.1 and the “TS” modifier on the claim as indicated in Table 2 above, along with the correct HCPCS/CPT code (Table 1), so that the provider/supplier can be reimbursed correctly for a screening service and not for another type of diabetes testing service.

- Medicare beneficiaries who have any of the following risk factors for diabetes are eligible for this screening benefit:

Hypertension

Dyslipidemia

Obesity (a body mass index equal to or greater than 30 kg/m2)

Previous identification of elevated impaired fasting glucose or glucose tolerance

or

Medicare beneficiaries who have a risk factor consisting of at least two of the following characteristics are eligible for this screening benefit:

Overweight (a body mass index greater than 25, but less than 30 kg/m2)

A family history of diabetes

Age 65 years or older

A history of gestational diabetes mellitus or of delivering a baby weighing greater than 9 pounds