Medicare Payment for Clinical Laboratory Services
Before Medicare pays for any test or diagnostic service, two basic criteria must be met:
(1) the service must be covered by Medicare (e.g., certain procedures such as
routine screening tests are not covered) and
(2) the service must be medically necessary or indicated.
Once these two criteria are met, Medicare pays for most clinical laboratory tests based on
the Laboratory Fee Schedule. Each carrier publishes a unique laboratory fee schedule and
adjusts payment levels annually on January 1st based on Congressional budget
recommendation.
Medicare payment for clinical laboratory tests is always the lesser of the fee schedule
amount or the actual amount billed. The provider must accept the Medicare reimbursement
as payment in full for a laboratory test. Medicare patients may NOT be billed for any
additional amounts. Tests must be billed directly to Medicare by the laboratory or physician
performing the test. If an outside laboratory performs a test on a referral from a physician,
only the reference laboratory may legally bill Medicare for the procedure.
Procedure (CPT) Codes and Modifiers
The CPT codes for Glycated Hemogobin (A1c) determinations are:
83036 Hemoglobin; glycated (A1c)
83036QW Hemoglobin; glycated (A1c) using CLIA waived method
Medicare reimbursement for CPT codes 83036 and 83036QW is $13.42 in all states
except:
Idaho: $9.66 Maryland: $12.66 Oklahoma: $11.95
Rhode Island: $12.09 South Dakota: $12.86 Wyoming: $10.49
Diagnosis (ICD-9) Codes
An appropriate diagnosis (ICD-9) code (or narrative description) must be indicated for each
service or supply billed under Medicare Part B. ICD-9-CM is an acronym for International
Classification of Diseases, 9th Revision, Clinical Modification.
When a patient presents with an undiagnosed illness, the ICD-9 code is determined by the
"signs and symptoms" present. Symptoms are defined as what the patient tells the
physician. Signs are what the physician observes as part of his examination of the patient.
Definitive ICD-9 codes should only be assigned and recorded in the medical record after a
diagnosis is clearly determined. Terms such as "rule out", "probable", and "suspected"
should NOT be used since they can not be coded as such and may be interpreted as a firm
diagnosis by a third party payer.
Before Medicare pays for any test or diagnostic service, two basic criteria must be met:
(1) the service must be covered by Medicare (e.g., certain procedures such as
routine screening tests are not covered) and
(2) the service must be medically necessary or indicated.
Once these two criteria are met, Medicare pays for most clinical laboratory tests based on
the Laboratory Fee Schedule. Each carrier publishes a unique laboratory fee schedule and
adjusts payment levels annually on January 1st based on Congressional budget
recommendation.
Medicare payment for clinical laboratory tests is always the lesser of the fee schedule
amount or the actual amount billed. The provider must accept the Medicare reimbursement
as payment in full for a laboratory test. Medicare patients may NOT be billed for any
additional amounts. Tests must be billed directly to Medicare by the laboratory or physician
performing the test. If an outside laboratory performs a test on a referral from a physician,
only the reference laboratory may legally bill Medicare for the procedure.
Procedure (CPT) Codes and Modifiers
The CPT codes for Glycated Hemogobin (A1c) determinations are:
83036 Hemoglobin; glycated (A1c)
83036QW Hemoglobin; glycated (A1c) using CLIA waived method
Medicare reimbursement for CPT codes 83036 and 83036QW is $13.42 in all states
except:
Idaho: $9.66 Maryland: $12.66 Oklahoma: $11.95
Rhode Island: $12.09 South Dakota: $12.86 Wyoming: $10.49
Diagnosis (ICD-9) Codes
An appropriate diagnosis (ICD-9) code (or narrative description) must be indicated for each
service or supply billed under Medicare Part B. ICD-9-CM is an acronym for International
Classification of Diseases, 9th Revision, Clinical Modification.
When a patient presents with an undiagnosed illness, the ICD-9 code is determined by the
"signs and symptoms" present. Symptoms are defined as what the patient tells the
physician. Signs are what the physician observes as part of his examination of the patient.
Definitive ICD-9 codes should only be assigned and recorded in the medical record after a
diagnosis is clearly determined. Terms such as "rule out", "probable", and "suspected"
should NOT be used since they can not be coded as such and may be interpreted as a firm
diagnosis by a third party payer.
