Academy Wants Fair Payment for Diabetes Testing

The AAFP continues to fight for family physicians who want to provide the best possible care for their patients with diabetes. At issue is fair payment for CPT code 83037 -- a code that covers an affordable, self-contained hemoglobin A1C testing system designed for use by office-based physicians.

The Academy's history of disagreement with CMS about this particular code dates back to July 2005. At that time, and several times thereafter, the Academy requested that CMS set the payment rate for this code no lower than $21.06 and suggested that a more accurate payment would be at or above $34.

Despite the Academy's continuing efforts, "It has come to our attention that many (i.e., 29) of the 56 Medicare carriers have set their payment for 83037 at $13.56," wrote AAFP Board Chair Mary Frank, M.D., of Mill Valley, Calif., in a recent letter to Tom Gustafson, Ph.D., deputy director of CMS' Center for Medicare Management.

"We have concerns with this payment level," said Frank.

Frank pointed out in the letter that CMS last year instructed Medicare payers to "gap fill" CPT code 83037 for 2006, meaning that carriers could determine a payment amount using available information sources within their service areas. However, said Frank, gap filling does not permit carriers to "crosswalk" or pay like amounts for CPT code 83037 and CPT code 83036. The latter CPT code was specifically established for bench-top analyzers used by laboratories and diabetes specialists. It provides for a lower -- yet adequate -- payment to those entities because of the high volume of tests they run.

"It appears that most of the carriers have subverted CMS' intent by proceeding to cross-walk payment of 83037 to 83036," said Frank, thus resulting in an unreasonably low payment for the service provided by family physicians.

"A gap-fill amount of $13.56 does not adequately cover the cost of administering this test in a physician's office," she said.

Frank pointed out, once again, that diabetes management in the United States is inadequate, and that improved access to A1C testing in the primary care setting would help improve the situation. "Real-time A1C (testing), at the time of the patient visit, is required for effective and intensive management that is proven to improve the health status for patients with diabetes," said Frank.

"Self-contained systems approved by FDA for home use, as represented by CPT code 83037, will increase access for those practices or situations where a low volume of tests is conducted," said Frank. "Appropriate gap-filling of the payment for this test … will support such access," she added.

Frank acknowledged that CMS has asked carriers to submit, by Sept. 1, a revised gap-fill payment. In addition to those actions, Frank asked CMS to