If you go back to tables released when PAMA pricing was new in 2018, you'll find that the surveyed median price of 83036 - laboratory hemoglobin A1c - was $8.50 (the fee schedule was $13.32). And the surveyed median price of 83037 - POCT hemoglobin A1c - was $22.50, almost three times as high.
Yet the price of either 83036 or 83037 is now $9.52.
What's up????
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| 83036 83037 in PAMA 2018 |
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Here's an AI-generated review of episodes and actions that I lived through years ago.
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83037 was born as a higher-paid point-of-care A1c code in 2006–2007, but Section 113 of the 2007 Medicare/Medicaid/SCHIP Extension Act mandated that any FDA-home-use HbA1c test (83037) be paid at the same rate as standard HbA1c (83036), effective April 1, 2008. CMS implemented this via a one-time transmittal, and the parity rule remains in force.
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In 2023 CMS Part B data, for 83036 there were $132M in payments, top labs being LabCorp and Quest, that's about 130,000 tests. For 83037, there were only $738K in payments (about 70,000 tests).
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Here’s the back-story in “policy-wonk” form. I thought it was a pretty amazing job of AI-driven automatic internet research and writing.
1. Why 83037 was created
CPT 83037 was introduced in 2006 as a new code for HbA1c testing performed by a device cleared by FDA for home use (i.e., a kit-type methodology distinct from conventional lab analyzers). Centers for Medicare & Medicaid Services+1
CMS treated 83037 as a separate HCPCS code under the glycated hemoglobin NCD and opened a national coverage analysis specifically to add it to the HbA1c NCD. The AMA explicitly commented that:
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83037 was intended for rapid, point-of-care A1c testing in the presence of the physician, not for unsupervised home self-testing. Centers for Medicare & Medicaid Services+1
So from the start, 83036 = standard lab HbA1c; 83037 = POC / kit-based method using an FDA-cleared “home-use” device, but done in the office.
2. CMS initial pricing: 83037 ends up higher than 83036
When 83037 appeared on the lab fee schedule:
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For CY 2006, CMS directed gapfill pricing by local carriers. Centers for Medicare & Medicaid Services
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For CY 2007, CMS crosswalked 83037 to 82985 (glycated protein), which produced a significantly higher national rate than the existing price for 83036. Centers for Medicare & Medicaid Services
Contemporaneous reporting from AAFP notes that:
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Many carriers had been paying around $13.56 for HbA1c;
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After CMS’ 2007 move, payment for 83037 increased to a national average of about $21.06, and AAFP had lobbied for this higher rate to support point-of-care testing in primary care. AAFP+1
So by 2007 you had:
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83036 – conventional lab HbA1c, lower CLFS rate (~$13.56).
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83037 – POC / home-device HbA1c, higher CLFS rate (~$21).
From a lab-industry perspective, that reversed the usual hierarchy (kit method > analyzer method) and raised concerns that a relatively simple waived kit had been “over-rewarded” while high-volume reference labs were locked into lower payment.
3. The “Congressional fix”: Section 113 of the MMSCHIP Extension Act (P.L. 110-173)
Those concerns resulted in a statutory “correction.”
In late 2007, Congress enacted the Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSE / MMSCHIP; P.L. 110-173). Section 113 specifically targets HbA1c test payment:
In the case of any diagnostic laboratory test for HbA1c that is labeled by FDA for home use and furnished on or after April 1, 2008, the payment rate for such test shall be the same as the payment rate for a glycated hemoglobin test identified by HCPCS 83036 (as of Oct 1, 2007). Every CRS Report+1
CMS implemented this in a One-Time Notification (Transmittal R331OTN), which:
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Reviews the history (gapfill in 2006; crosswalk to 82985 in 2007).
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States that, effective for tests furnished on or after April 1, 2008, the price for 83037 (and 83037QW) must be equal to the CLFS rate for 83036. Centers for Medicare & Medicaid Services+1
An AAPC / MLN “News Flash” for the clinical lab fee schedule mirrors this: for tests on or after April 1, 2008, payment for 83037/83037QW equals the 83036 rate. AAPC+1
A Congressional Research Service report on P.L. 110-173 summarizes the same change for policy staff: HCPCS 83037 (home-use HbA1c) is now paid at the rate established for 83036. Every CRS Report+1
In other words: Congress explicitly eliminated any pricing premium for 83037 over 83036.
4. How the “slipped into SCHIP” story looks in the record
Contemporaneous physician-press coverage gives a nice window into the politics:
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Jane Anderson, writing in Family Practice News / MDedge, reports that the reimbursement cut for fast in-office HbA1c tests (83037) was “mandated by a provision in the Medicare, Medicaid, and SCHIP Extension Act of 2007,” reversing CMS’ earlier 2006–2007 decision to pay more. MDedge+1
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AAFP coding expert Cynthia Hughes is quoted as saying the provision was “slipped into SCHIP” and that it would take another act of Congress to undo it. MDedge+1
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The same article states that the statutory language requires point-of-care HbA1c tests billed under 83037 to be paid at the same rate as HbA1c tests billed under 83036, i.e., at the lab-test rate. MDedge+1
AAFP’s line was that this would reduce payment for POC kits from ~$21 back down to ~$13.50, making in-office HbA1c less attractive for primary-care practices and potentially reducing patient access to same-visit counseling. The Hospitalist Blog+1
The documentation doesn’t spell out “reference lab lobbying” in so many words, but the economic logic is plain:
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Point-of-care kit (83037) had been paying significantly more per test than analyzer-based HbA1c (83036). AAFP+1
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Section 113 eliminates that differential and produces Medicare savings, as CRS notes in its budget table. Every CRS Report
Industry accounts at the time generally describe this as larger stakeholders pushing to avoid a precedent where a waived kit method is permanently priced above the “gold standard” lab method.
5. Where that leaves coding today (for context)
Because of Section 113 and the CMS implementation:
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83036 remains the dominant HbA1c code for laboratory-based testing.
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83037 is still used for rapid, CLIA-waived point-of-care HbA1c in a physician’s office with an FDA-cleared device, but its fee schedule amount is locked to the 83036 rate under federal statute for any HbA1c test labeled for home use and furnished on or after April 1, 2008. Centers for Medicare & Medicaid Services+1
That’s why, despite the coding distinction (lab vs POC), you do not see a durable national price premium for 83037 over 83036 on the CLFS.
6. Policy take-aways for experts
For a policy audience, this episode illustrates several recurring themes:
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Coding vs. Payment vs. Methodology: Creating a separate CPT code (83037) for a device-specific or site-of-service-specific method can unintentionally create a payment wedge between similar clinical services (lab analyzer vs waived kit). CMS initially amplified this by crosswalking to a higher-priced code (82985). Centers for Medicare & Medicaid Services+1
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Stakeholder conflict and “precedent anxiety”: Physician groups (e.g., AAFP) lobbied for higher 83037 payment to support POC testing. Other stakeholders—most plausibly large reference labs and cost-conscious policymakers—were concerned about establishing a precedent where kit methods or POC settings draw systematically higher reimbursement than core lab tests. The legislative fix can be read as Congress siding with the “parity” position.
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Use of narrow statutory riders: Section 113 is a classic micro-targeted provision—one paragraph in a large Medicare/SCHIP bill that permanently fixes the relationship between two lab codes. CRS explicitly flags this as a discrete “payment rate for certain diagnostic laboratory tests” provision affecting HCPCS 83036/83037. Every CRS Report+1
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Durability of statutory corrections: As Hughes noted, once you’ve hard-wired the relationship into statute (“same rate as 83036”), reversing it requires another act of Congress, not just a CMS rule change. MDedge
