11/20/2012 - Medical Coding - Medical Billing - Medical Auditing

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Physician

Radiology Tech

Physician Assistant (PA) Nurse Practitioner (NP)

Physical Therapist Lab Tech Nurses

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Source: Novitas Solutions https://www.novitas-solutions.com/policy/jh/l32614-r1.html


Indications and Limitations of Coverage and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this

entire LCD) as if they are covered. When billing for non-covered services, use the appropriate

modifier.

Medicare generally considers vitamin assay panels (more than one vitamin assay) a screening procedure

and therefore, non-covered. Similarly, assays for micronutrient testing for nutritional deficiencies that

include multiple tests for vitamins, minerals, antioxidants and various metabolic functions are never

necessary. Medicare reimburses for covered clinical laboratory studies that are reasonable and necessary

for the diagnosis or treatment of an illness. Many vitamin deficiency problems can be determined from a

comprehensive history and physical examination. Any diagnostic evaluation should be targeted at the

specific vitamin deficiency suspected and not a general screen. Most vitamin deficiencies are nutritional in

origin and may be corrected with supplemented vitamins.

Most vitamin deficiencies are suggested by specific clinical findings. The presence of those specific clinical

findings may prompt laboratory testing for evidence of a deficiency of that specific vitamin. Certain other

clinical states may also lead to vitamin deficiencies (malabsorption syndromes, etc).

https://www.novitas-solutions.com/policy/jh/l32614-r1.html










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Limitations:

For Medicare beneficiaries, screening tests are governed by statute (Social Security Act 1861(nn)). Vitamin or

micronutrient testing may not be used for routine screening.

Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure

adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon

the indication and other mitigating factors.

Assays of selenium (84255), functional intracellular analysis (84999) or total antioxidant function (84999) are

non-covered services. Assays of vitamin testing, not otherwise classified (84591), are not covered since all

clinically relevant vitamins have specific assays.

The following are pertinent laboratory tests for which frequency limitations will be specified [note this should be

all the CPT codes in the list below, except for those that are non-covered]:

Vitamins and metabolic function assays: 25-OH Vitamin D-3, Carnitine, Vitamin B-12, Folic Acid (Serum),

Homocystine, Vitamin B-6, Vitamin B-2, Vitamin B-1, Vitamin E, Fibrinogen, High-Sensitivity C-Reactive Protein

and Lipoprotein-associated phospholipase A 2 (Lp-PLA 2); Vitamin A; Vitamin K; and Ascorbic acid.


82180 Assay of ascorbic acid

82306 Vitamin d 25 hydroxy

82379 Assay of carnitine

82607 Vitamin B-12

82652 Vit d 1 25-dihydroxy

82746 Blood folic acid serum

83090 Assay of homocystine

CPT/HCPCS Codes

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American

Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short

CPT descriptors in policies published on the Web.

Note:

Code 82306 includes fractions, if performed.

Code 82652 includes fractions, if performed.











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252.00 - 252.02HYPERPARATHYROIDISM, UNSPECIFIED - SECONDARY HYPERPARATHYROIDISM, NON-

RENAL

252.08 OTHER HYPERPARATHYROIDISM

252.1 HYPOPARATHYROIDISM

268.0 RICKETS ACTIVE

268.2 OSTEOMALACIA UNSPECIFIED

268.9 UNSPECIFIED VITAMIN D DEFICIENCY

275.3 DISORDERS OF PHOSPHORUS METABOLISM

275.41 - 275.42 HYPOCALCEMIA - HYPERCALCEMIA

585.3 - 585.6 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) - END STAGE RENAL DISEASE

ICD-9 Codes that Support Medical Necessity

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and

electronic claims.

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists

include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not

on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT codes 82306 and 82652:

Covered for:

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http://www.hhs.gov/ocr/privacy/hipaa/enforcement/examples/allcases.html#case1

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http://oig.hhs.gov/fraud/PhysicianEducation/05compliance.asp

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Evaluation and Management Services—Use of Modifiers During the Global Surgery

Period

We will review the appropriateness of the use of certain claims modifier codes during the

global surgery period and determine whether Medicare payments for claims with modifiers

used during such a period were in accordance with Medicare requirements. Prior OIG

work found that improper use of modifiers during the global surgery period resulted in

inappropriate payments. The global surgery payment. includes a surgical service and

related preoperative and postoperative E/M services provided during the global surgery

period. (CMS’s Medicare Claims Processing Manual, Pub. 100-04, ch. 12, § 40.1.)

Guidance for the use of modifiers for global surgeries is in CMS’s Medicare Claims

Processing Manual, Pub. 100-04, ch. 12, § 30.

(OAS; W-00-13-35607; various reviews; expected issue date: FY 2013;

new start) Source: https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/WP01-Mcare_A+B.pdf

Sleep Testing—Appropriateness of Medicare Payments for Polysomnography

We will identify questionable billing patterns for Medicare sleep study services provided in

2009 and 2010. Medicare payments for polysomnography increased from $62 million in

2001 to $235 million in 2009, and coverage was also recently expanded. Sleep studies

are reimbursable for patients who have symptoms such as sleep apnea, narcolepsy, or

parasomnia in accordance with the CMS’s Medicare

Benefit Policy Manual, Pub. 102, ch. 15, § 70.

(OEI; 05-12-00340; expected issue date: FY 2013; work in progress)

Source:https://oig.hhs.gov/reports-and-publications/archives/workplan/2013/WP01-Mcare_A+B.pdf

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11/20/2012 - Medical Coding - Medical Billing - Medical Auditing

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