83036
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- The medical record must document and satisfy the criteria required for any NCCI-associated modifier that is reported.
- Claims must follow NCCI coding guidelines and applicable code-combination rules prior to billing Medicare.
- Documentation supporting that tests meet 'reasonable and necessary' criteria and applicable frequency limits must be maintained per Novitas LCD L35099.
- This article provides billing, coding and guideline information that complements Local Coverage Determination (LCD) L33431 for HbA1c; refer to LCD L33431 for clinical coverage criteria and specific documentation requirements.
Key Coverage Criteria
- Laboratory tests are covered when they meet the reasonable and necessary clinical criteria and frequency limitations specified in Novitas LCD L35099.
- Procedure codes are covered for the ICD-10-CM diagnoses listed as covered in the Medicare NCDs referenced at the CMS NCD ICD-10 laboratory list.
- Perform HbA1c testing at least twice per year in patients who are meeting individualized treatment goals and have stable glycemic control, defined as two consecutive HbA1c results meeting treatment goals.
- Perform HbA1c testing for beneficiaries with unstable or uncontrolled glycemia at intervals up to once every 3 months as allowed by the Lab NCD 190.21.
- Beneficiaries eligible for the Medicare home health benefit often have multiple coexisting illnesses and may have higher individualized HbA1c targets that justify more frequent testing.
- A laboratory service is reasonable and necessary only when ordered by a physician who uses the test result in the management of the beneficiary's specific medical problem.
5 Active Policies
A56420 — Billing and Coding: Frequency of Laboratory Tests
J12
L35099 — Frequency of Laboratory Tests
J12
A56686 — Billing and Coding: HbA1c
L33431 — HbA1c
ANTHEM-CG-LAB-25 — CG-LAB-25 Outpatient Glycated Hemoglobin and Protein Testing
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.