M1211 — Most recent glycemic status assessment (hba1c or gmi) level > 9.0%
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
- 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.
- Document two consecutive HbA1c results meeting treatment goals to support classification of 'stable glycemic control.'
- Provide medical records demonstrating medical necessity for any additional HbA1c tests beyond standard or NCD/local frequency limits when requesting reimbursement on appeal.
- Follow the Lab National Coverage Determination 190.21 for appropriate ICD-10 diagnosis codes and for use of alternative glycated protein or fructosamine testing when HbA1c is unreliable.
Key Coverage Criteria
- 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.
2 Active Policies
A56686 — Billing and Coding: HbA1c
L33431 — HbA1c
Related Codes
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