The Jurisdiction E, Part B Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of CPT® 82306 - Vitamin D. The quarterly edit effectiveness results from January 1, 2020 through March 31, 2020 are as follows:

Top Denial Reasons:

• Failure to Return Records.
• Documentation does not Support the Service Billed.
• Documentation was Missing and/or Incomplete.

Educational Resources

• How to Respond to ADR
• Signature Requirement Questions and Answers
• JE LCD L36692

Education

Medical Necessity

As laid out in section 1862(a)(1)(A) of Title XVIII of the Social Security Act, no Medicare payment may be made for items or services that are not reasonable and necessary for diagnosis or treatment of illness/injury or to improve the function of a malformed body part.

Medical necessity is a term used when determining whether a diagnosis or treatment by a physician is considered appropriate or inappropriate, based on medical standards of care. Medicare can only allow services that meet this standard. In order to be considered medically necessary, items and services must be proven as safe and effective.

Medicare is aware that some patients do and will require professional services at a greater frequency and duration than others, including more extensive diagnostic procedures. Documentation verifying medical necessity for such treatment must be recorded in the medical records. Documentation that the services were rendered is necessary in order for a claim to be properly evaluated. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.2.

Failure to Return Records

When the MAC requests documentation for prepayment review, it is the provider’s responsibility for the requested documentation to be received within 45 calendar days from the request. The MAC will not grant extensions to providers who need more time to comply with the request. Payment will not be made to any provider unless they have furnished the information as requested in order to determine the amounts due to the provider. Medicare will not pay for services unless they are deemed necessary and sufficient information is submitted that shows that services were provided. For payment, the services must be determined to be reasonable and necessary for the prevention or treatment of illness. Refer to Social Security Act 1815(a), 1833(e), 1862(a)(1)(A).

Insufficient Documentation

When additional documentation has been requested to verify compliance with the CPT®/HCPCS code billed and the submitted documentation lacks evidence to support that, the claim will be denied as the documentation submitted was incomplete and/or insufficient. Refer to Internet Only Manual (IOM), Publication (Pub) 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8(C).

JE LCD

Local Coverage Determination L36692 "TITLE" discusses the coverage requirements for these services. This LCD can be located at the following web address: https://med.noridianmedicare.com/web/jeb/policies/lcd/active. This LCD clarifies that measurement of 25-OH vitamin D level is indicated for patients with the following conditions: processes: chronick kidney disease stage III or greater, cirrhosis, hypocalcemia, hypercalcemia,

hypercalciuria, hypervitaminosis D, parathyroid disorders, malabsorption states, obstructive jaundice, osteomalacia. osteoporosis (if i. T score on DEXA scan, ii. History of fragility fractures or, iii. FRAX > 3% 10-year probability of hip fracture or 20% 10-year probability of other major osteoporotic fracture or, iv. FRAX > 3% (any fracture) with T-score v. Initiating bisphosphanate therapy (Vit D level should be determined and managed as necessary), osteosclerosis/petrosis

rickets, vitamin D deficiency on replacement therapy used to monitor the efficacy of treatment. Measurement of 1, 25-OH Vitamin D level is indicated for patients who have: unexplained hypercalcemia, unexplained hypercalciuria, suspected genetic childhood rickets, suspected tumor-induced osteomalacia or nephrolithiasis/hypercalciuria.

Limitations are listed in the LCD that testing may not be utilized for routine screening, both assays of vitamin D do not need to be performed for each of the above-mentioned conditions. Once a beneficiary has been shown to be vitamin D deficient, further testing may be medically necessary only to ensure adequate replacement has been accomplished. If Vitamin D level is between 20 and 50 ng/dl and patient is clinically stable, repeat testing is often unnecessary; if performed, documentation most clearly indicate the necessity of the test. If level 60 ng/dl, a subsequent level(s) may be reimbursed until the level is within the normal range.