Missouri

A service-specific probe review was completed for CPT code 83036 glycated hemoglobin (A1C) for specialty 69 (Independent Clinical Lab). Major issues identified were documentation not received and services not medically reasonable or necessary. WPS Medicare must receive the documentation requested within 45 days or we will deny the service. It is important providers submit all requested documentation in a timely manner. It is not reasonable and necessary to perform procedure code 83036 more often than once every three months.

Medical Review has completed an article for the Widespread Service-Specific Probe for Hemoglobin A1C, CPT code 83036. Records were reviewed to determine whether the procedure code billed met all documentation requirements for the services billed. Services for CPT code 83036 were denied if the documentation did not support the service billed as defined in the NCD 190.21 - Glycated Hemoglobin/Glycated Protein.

The major issues identified that led to the denial of 70.00% of these services are as follows:

CMS is required to compete the A/B MAC workloads at least once every 5 years. It recently did so for the Jurisdiction 5 A/B MAC and awarded this workload to WPS, the incumbent contractor. CMS has determined that it will not need to change the current Jurisdiction 5 workload numbers when this new contract is implemented. This applies to the Part B states of: Iowa, Kansas, Missouri and Nebraska Providers as of Sept. 10, 2012.

• Original claims must be filed by the provider and received by the state agency within twelve (12) months from the date of service. Any claims that originally were submitted and received within twelve (12) months from the date of service, but were denied or returned to the provider, must be resubmitted and received within twenty-four (24) months of the date of service.