Medicare Issues Clarification and Guidance for Diabetes Screening Tests

(PYA Alert dated February 16, 2005)

Medicare beneficiaries at risk for diabetes are eligible for a new screening benefit effective January 1, 2005, as provided by Section 613 of the Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA). Diabetes screening tests include a fasting blood glucose and a post-glucose challenge test.

The following Level I HCPCS codes are to be billed for diabetes screening:
82947 Glucose, quantitative, blood (except reagent strip) 82950 Glucose, post-glucose dose (includes glucose) 82951 Glucose, tolerance test (GTT), three specimens (includes glucose)

Patients meeting the definition of "pre-diabetes" are eligible for two screening tests per year, while patients who have never been tested or were not diagnosed with pre-diabetes are eligible for one screening per year.

Medicare claims for "pre-diabetes" patients receiving the screening should append the modifier "TS" to the Level I HCPCS codes as listed above.

When submitting a claim to the Medicare carrier for diabetes screening, diagnosis code V77.1 should be reported.

Transmittal #457, dated January 28, 2005 from CMS provides the following information:

"Individuals who have any of the following risk factors for diabetes are eligible for this benefit:

• Hypertension;
• Dyslipidemia;
• Obesity (a body mass index equal to or greater than 30 kg/m2), or
• Previous identification of elevated impaired fasting glucose or glucose intolerance.

Also, individuals who have a risk factor consisting of at least two of the following characteristics are eligible for this benefit:

• Overweight (a body mass index > 25, but < 30 kg/m2),
• A family history of diabetes,
• Age 65 years or older,
• A history of gestational diabetes mellitus, or delivering a baby weighing > 9 lbs."

Additional information from this transmittal may be obtained from the CMS website at http://www.cms.hhs.gov/manuals/pm_trans/R457CP.pdf

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