Diabetes is one of the most common diseases in the United States. Around 38 million Americans, or every 1 in 10, have diabetes, and about 90% to 95% of them have type 2 diabetes. Because of its high prevalence, precise diagnoses and effective treatments are available nationwide. However, many healthcare providers face challenges while billing for these services.
In this blog, we will discuss CPT code 83036, which represents a laboratory test for type 2 diabetes. We have compiled all the information you need to know about this code. By the end of this blog, you should be clear about the practical usage of this code, applicable modifiers, and essential billing guidelines.
CPT Code 83036 – Description
CPT code 83036 refers to a blood test called the Hemoglobin A1C (HbA1c). It diagnoses type 2 diabetes and measures the amount of blood sugar that attaches to the hemoglobin molecules in the red blood cells (RBCs). Simply speaking, it helps the physician assess a patient’s blood sugar levels in the past three months.
Why does HbA1c specifically measure the blood sugar for three months, and how are RBCs involved in all of this? Let us explain. During the process called glycosylation, glucose molecules (sugar) react with hemoglobin in the RBCs to form a bond. The higher the concentration of glucose in the bloodstream, the higher the levels of glucose-hemoglobin bonds. Now, it is important to note that sugar remains attached to the hemoglobin molecule for the entire lifecycle of the RBC, which is three months.
The A1C test reveals the percentage of sugar sticking to red blood cells. However, the level of A1C in a healthy, normal person should be less than 7%. Below is the percentage range physicians generally use to diagnose diabetes or pre-diabetes.
- Normal: If the A1C percentage is below 5.7.
- Pre-diabetes: If the A1C percentage is between 5.7 and 6.4.
- Diabetes: If the A1C percentage is higher than 6.5.
Scenarios Where CPT Code 83036 is Applicable
Type 2 diabetes (T2D) is a chronic illness caused by constant high blood sugar (hyperglycemia). It occurs when the pancreas fails to make enough insulin, when organs fail to use insulin appropriately, or in certain cases, both. This leads to several health issues, including stroke, kidney disease, and heart disease, if it is left untreated for a long time. However, the Hemoglobin A1C (HbA1c) test helps physicians diagnose Type 2 diabetes early on.
The scenarios listed below illustrate the need for an A1C test and the usage of CPT code 83036 to report it for billing purposes.
Increased Thirst (Polydipsia)
Increased thirst is a symptom of diabetes. In medical terminology, this condition is also called polydipsia. Let’s say a 40-year-old man visits the clinic believing that he has diabetes. He talks to the physician about his symptoms, such as feeling thirsty most of the time and urinating more frequently. He also complains of blurred vision while working or traveling for work. The physician performs an A1C blood test to determine or rule out type 2 diabetes. So, in this case, the physician can bill his services with CPT code 83036.
Overweight (Obesity)
There is a high chance of type 2 diabetes in obese people. According to research, almost 90% of obese people are diagnosed with type 2 diabetes. So, imagine an obese man in his mid-thirties visiting the clinic with potential symptoms of diabetes, like fatigue and numb hands and feet. The physician decides to check his sugar levels for the past 120 days, so he conducts an HbA1c test. In this scenario, he can use CPT code 83036 for his services.
Pre-Diabetes
Let’s say a patient who has been diagnosed with pre-diabetes by a physician visits the clinic for a standard examination. He does, however, demonstrate to the physician that his wounds are healing more slowly than usual. Furthermore, he has lost a significant amount of weight without even trying. The physician suspects elevated blood sugar levels. So, he performs an A1C test to examine the patient’s blood sugar levels in the previous three months. In this case, the healthcare provider can use CPT code 83036 to bill for his services.
Applicable Modifiers for CPT Code 83036
Below is a list of a few commonly used modifiers used with CPT code 83036.
Modifier 91
Modifier 91 explains to the insurance payer that the clinical lab test was repeated on the same day for the same patient to obtain subsequent results. So, if the hemoglobin HbA1c test was performed again on the same day to track the rise and fall of glucose percentage in the RBCs, then modifier 91 will be appended to CPT code 83036.
Modifier QW
The QW modifier indicates that a clinical laboratory test is waived for the Clinical Laboratory Improvement Amendments (CLIA) regulations, and the provider holds a waiver certificate from CLIA.
Physicians must append the QW modifier with CPT code 83036 because the hemoglobin A1C test is quite simple to perform and does not require the implementation of CLIA protocols. Hence, 83036 is a CLIA-waived test and should be reported as such to the Centers for Medicare & Medicaid Services (CMS) for proper reimbursement.
CPT Code 83036 – Billing & Reimbursement Guidelines
The following are the billing guidelines and reimbursement guidelines for CPT code 83036 that can not be overlooked.
Ensure Correct Information in Documents
Reimbursement for every CPT code requires proper documentation. Healthcare professionals must provide the patient’s clinical history, the rationale for the test, and any potential risk factors associated with the procedure. Furthermore, these documents should be checked and signed by an authoritative senior professional to ensure the authenticity of the information.
Pair with Accurate Diagnostic Codes
The claims you are submitting for reimbursement must provide proof of medical necessity for the procedure using appropriate ICD-10 diagnostic codes. The following are examples of a few ICD-10 codes frequently used with CPT code 83036 that help demonstrate the necessity of the hemoglobin A1C lab test.
When the test is diagnostic:
- E66 – Overweight and obesity
- E66.9 – Obesity, unspecified
- Z68.25 – Body mass index [BMI] 25.0-25.9, adult
- Z68.29 – Body mass index [BMI] 29.0-29.9, adult
- R63.1 – Polydipsia
When the test is to monitor type 2 diabetes:
- E11 – Type 2 diabetes mellitus
- E11.9 – Type 2 diabetes mellitus without complications
- R73.03 – Prediabetes
Follow Specific Payer Guidelines
Healthcare providers must cross-check the payer-specific guidelines of each patient’s claim. Different patients have different insurance plans. Furthermore, these insurance companies or Medicare/Medicaid may have particular policies and criteria that affect reimbursement for the 83036 CPT code.
The frequency of testing, the standards for medical necessity, and any documentation needs may all be specified in these policies. Healthcare providers should be aware of the payment policies to ensure claim acceptance and accurate compensation.
Use Category II Codes
Category II codes give additional information about the service, particularly for quality reporting and performance evaluation. When you perform an HbA1c test on a patient, you might need to report specific patient information or test results using Category II codes.
This information may include details like the patient’s diabetes status, treatment goals, or whether the test was performed as part of a screening or monitoring program. Category II codes are widely advised to enhance quality improvement and performance measurement initiatives in diabetes care, although it is not required for all payers.
Review Limitation – Frequency of Tests
Medicare considers the Hemoglobin A1C test a medical necessity and reimburses physicians according to its policies set in LCD documents. However, it does impose some limitations, such as allowing it twice a year for people with managed diabetes and once every 3 months for people with uncontrolled blood glucose levels. For some payers, pregnant women with diabetes can get their tests done once every month.
Conclusion
CPT code 83036 is used to report the procedure of a laboratory test called Hemoglobin A1C. It provides important information on a patient’s long-term blood sugar management and is crucial for diagnosing, treating, and monitoring diabetes. With the help of this test, healthcare professionals monitor glucose trends and create a treatment plan for patients.
You must add the required modifiers and adhere to the billing criteria, like providing relevant documentation, to secure full reimbursement of your services. On the other hand, you can hire pathology billing services for clean claim submissions, compliance with regulations, and a lower chance of claim denials.
