Local Coverage Determination (LCD): Vitamin D …

1 Local Coverage Determination (LCD): Vitamin D Assay testing ( L30273 ) Contractor InformationContractor NameNovitas Solutions, Number12502 Contract TypeA and B MACLCD InformationDocument InformationLCD IDL30273 JurisdictionPennsylvaniaLCD TitleVitamin D Assay TestingOriginal Effective DateFor services performed on or after 10/28/2009 Revision Effective DateFor services performed on or after 09/01/2014 Retirement DateN/ANotice Period Start Date09/11/2009 Notice Period End DateN/ARevision Ending Date N/AAMA CPT / ADA CDT Copyright StatementCPT only copyright 2002 -2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use.

2 The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association. UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves Page 2 of 304/8/2015 right to change the copyright notice from time to time upon written notice to National Coverage PolicyTitle XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

3 Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations. Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the GuidanceCoverage Indications, Limitations, and/or Medical NecessityCompliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review D is called a " Vitamin " because of its exogenous source, predominately from oily fish in the form of Vitamin D2 and Vitamin D3. It is more accurate to consider fat-soluble Vitamin D as a steroid hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol.

4 Clinical disorders related to Vitamin D may arise because of altered availability of the parent Vitamin D, altered conversion of Vitamin D to its predominant metabolites, altered organ responsiveness to dihydroxylated metabolites and disturbances in the interactions of the Vitamin D metabolites with PTH and calcitonin. This LCD identifies the indications and limitations of Medicare Coverage and reimbursement for these :Measurement of Vitamin D levels is indicated for patients with: chronic kidney disease stage III or greater cirrhosis fibromyalgia granuloma forming diseases hypocalcemia hypercalcemia hypovitaminosis D hypervitaminosis D long term use of anticonvulsants or glucocorticoids and other medications known to lower Vitamin D levels malabsorption states obstructive jaundice osteomalacia osteoporosis osteogenesis imperfecta osteosclerosis psoriasis rickets Vitamin D deficiency on replacement therapy.

5 To monitor the efficacy of treatment Limitations:For Medicare, testing may not be used for routine assays of Vitamin D and its metabolites need not be performed for each of the above conditions. Often, one type is more appropriate for a certain disease state than another. The most common type of Vitamin D deficiency is that of 25 OH Vitamin D. A much smaller percentage of 1, 25 dihydroxy Vitamin D deficiency exists; mostly in those with renal disease. It is expected that the medical record will justify the tests chosen for a particular disease entity, that all available components of 25 OH Vitamin D and other metabolite levels will not be performed routinely on every patient and that supportive documentation for test choices will be available to the Contractor upon Contractor does not expect to receive billing for the various component sources of 25 OH Vitamin D separately (such as stored D or diet derived D).

6 Only one 25 OH Vitamin D assay will be considered for reimbursement on any particular day, if medically necessary, for the patient s a beneficiary has been shown to be Vitamin D deficient, further testing may be medically necessary only to ensure adequate replacement has been accomplished for this Vitamin deficiency, although, generally, other parameters are 3 of 304/8/2015 InformationBill Type CodesContractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that Coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all Inpatient (Including Medicare Part A)12xHospital Inpatient (Medicare Part B only)13xHospital Outpatient14xHospital - Laboratory Services Provided to Non-patients18xHospital - Swing Beds21xSkilled Nursing - Inpatient (Including Medicare Part A)22xSkilled Nursing - Inpatient (Medicare Part B only)23xSkilled Nursing - Outpatient72xClinic - Hospital Based or Independent Renal Dialysis Center83xAmbulatory Surgery Center85xCritical Access HospitalRevenue CodesContractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

7 In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this Coverage Determination . Complete absence of all Revenue Codes indicates that Coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue - General Classification0301 Laboratory - Chemistry0309 Laboratory - Other LaboratoryCPT/HCPCS CodesGroup 1 ParagraphItalicized and/or quoted material is excerpted from the American Medical Association,Current Procedural Teminology (CPT) 1 Codes82306 Vitamin d 25 hydroxy82652 Vit d 1 25-dihydroxyICD-9 Codes that Support Medical NecessityGroup 1 Paragraph : It is the provider s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim(s) following ICD-9-CM codes support the medical necessity of CPT code 1 TUBERCULOUS COMPLEX UNSPECIFIED TUBERCULOUS COMPLEX BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT TUBERCULOUS COMPLEX BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION RESULTS UNKNOWN (AT PRESENT) TUBERCULOUS COMPLEX TUBERCLE BACILLI FOUND (IN SPUTUM) BY TUBERCULOUS COMPLEX TUBERCLE BACILLI NOT FOUND (IN SPUTUM)

8 BY MICROSCOPY BUT FOUND BY BACTERIAL TUBERCULOUS COMPLEX TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED 4 of 304/8/2015 TUBERCULOUS COMPLEX TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS CONFIRMATION PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION RESULTS UNKNOWN (AT PRESENT) PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS TUBERCLE BACILLI FOUND (IN SPUTUM) BY PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY BUT FOUND BY BACTERIAL PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED PLEURISY IN PRIMARY PROGRESSIVE TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) PRIMARY PROGRESSIVE TUBERCULOSIS CONFIRMATION PRIMARY PROGRESSIVE TUBERCULOSIS BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT PRIMARY PROGRESSIVE TUBERCULOSIS BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION RESULTS UNKNOWN (AT PRESENT) PRIMARY PROGRESSIVE TUBERCULOSIS TUBERCLE BACILLI FOUND (IN SPUTUM) BY PRIMARY PROGRESSIVE TUBERCULOSIS TUBERCLE BACILLI NOT FOUND (IN SPUTUM)

9 BY MICROSCOPY BUT FOUND BY BACTERIAL PRIMARY PROGRESSIVE TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED PRIMARY PROGRESSIVE TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) TUBERCULOUS INFECTION UNSPECIFIED TYPE CONFIRMATION TUBERCULOUS INFECTION UNSPECIFIED TYPE BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT TUBERCULOUS INFECTION UNSPECIFIED TYPE BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION RESULTS UNKNOWN (AT PRESENT) TUBERCULOUS INFECTION UNSPECIFIED TYPE TUBERCLE BACILLI FOUND (IN SPUTUM) BY TUBERCULOUS INFECTION UNSPECIFIED TYPE TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY BUT FOUND BY BACTERIAL TUBERCULOUS INFECTION UNSPECIFIED TYPE TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED TUBERCULOUS INFECTION UNSPECIFIED TYPE TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) OF LUNG INFILTRATIVE CONFIRMATION OF LUNG INFILTRATIVE BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT OF LUNG INFILTRATIVE BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION RESULTS UNKNOWN (AT PRESENT) OF LUNG INFILTRATIVE TUBERCLE BACILLI FOUND (IN SPUTUM) BY OF LUNG INFILTRATIVE TUBERCLE BACILLI NOT FOUND (IN SPUTUM)

10 BY MICROSCOPY BUT FOUND BY BACTERIAL OF LUNG INFILTRATIVE TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED OF LUNG INFILTRATIVE TUBERCLE BACILLI NOT FOUND BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) OF LUNG NODULAR UNSPECIFIED OF LUNG NODULAR BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT OF LUNG NODULAR BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION RESULTS UNKNOWN (AT PRESENT) OF LUNG NODULAR TUBERCLE BACILLI FOUND (IN SPUTUM) BY OF LUNG NODULAR TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY BUT FOUND BY BACTERIAL OF LUNG NODULAR TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED OF LUNG NODULAR TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) OF LUNG WITH CAVITATION UNSPECIFIED OF LUNG WITH CAVITATION BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION NOT DONEPage 5 of 304/8/2015 OF LUNG WITH CAVITATION BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION RESULTS UNKNOWN (AT PRESENT) OF LUNG WITH CAVITATION TUBERCLE BACILLI FOUND (IN SPUTUM) BY OF LUNG WITH CAVITATION TUBERCLE BACILLI NOT FOUND (IN SPUTUM) BY MICROSCOPY BUT FOUND BY BACTERIAL OF LUNG WITH CAVITATION TUBERCLE BACILLI NOT FOUND B