Planned Widespread Service-Specific Probe Review for Hemoglobin A1C CPT Code 83036 – Specialty 69 Independent Clinical Laboratory

To access the medical necessity of claims submitted frequently for CPT code 83036, a Widespread Prepayment Service Specific Probe Review will be conducted for Specialty 69 (Independent Clinical Laboratory) in the J5 Jurisdiction (Iowa, Kansas, Missouri, and Nebraska). This review will involve a random sample of 100 claims submitted from a cross-section of all providers or suppliers in a defined group who bill the particular item or service in question. The medical records will be requested for the sample and will be reviewed. An Additional Documentation Letter (ADR) will be sent requesting medical records for Hemoglobin A1C tests billed on claims selected for this probe. If an ADR is received, it is the billing provider’s responsibility to provide the required pre-existing documentation necessary to conduct a medical record review. If you receive an ADR letter for this Service-Specific Review, please submit the requested information within 30 days of receipt of the ADR. Failure to submit the requested documentation in a timely fashion may result in denial or reduction of services. All documentation must be legible. For clarity, you may need to submit transcribed notes along with the original pre-existing medical record documentation. WPS Medicare: MAC J5 contract, administering Part A and B benefits in Iowa, Kansas, Missouri, and Nebraska ; Legacy Medicare Part B administering Part B benefits in Wisconsin, Illinois, and Minnesota ; future MAC J8 contract, administering Part A and B benefits in Indiana and Michigan.

Source: https://www.wpsgha.com