Utilization Guidelines
In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.
Medicare recognizes certain tests may exceed the stated frequencies. Should a denial occur, additional documentation can be submitted to support medical necessity. Payment for additional tests may be allowed in selected circumstances when, upon medical review, the medical necessity of additional services is demonstrated.
Following a review of utilization data at various percentiles of units billed per year, the following frequency limitations are established and are as follows:
Assay of ascorbic acid, 1 time per year
Vitamin d 25 hydroxyl, up to 3 times per year
Assay of carnitine, up to 3 times per year
Vitamin b-12, up to 3 times per year
Vitamin d 1 25-dihydroxy, up to 2 times per year
Assay of folic acid serum, up to 3 times per year
Assay of homocysteine, 1 time per year
Assay lipoprotein pla2, 1 time per year
Assay of vitamin b-6, 1 time per year
Assay of vitamin b-2, 1 time per year
Assay of vitamin b-1, 1 time per year
Assay of vitamin e, 1 time per year
Assay of vitamin a, 1 time per year
Assay of vitamin k, 1 time per year
Fibrinogen antigen, up to 3 times per year
Cell function assay w/stim frequencies not determined
Overutilization
Please keep in mind of certain Medicare limitations regarding reimbursement for laboratory testing. Restrictions include but are not limited to the following tests:
- Glycohemoglobin (may be ordered once every 90 days)
- Ferritin (may be ordered once every 60 days)
- Lipid Profile (may be ordered annually but more frequently with the appropriate diagnosis such as hypercholesterolemia, hyperlipidemia, ETC).
Restrictions for Medicare coverage of thyroid function testing have resulted in the following protocol to be put in place. Medicare coverage includes the following three ordering patterns:
- TSH, Thyroxin (T4 Total) and T3 Uptake;
- TSH and Free T4; or
- Any thyroid test ordered single-handedly.
Medicare coverage considers C. Reactive Protein High Sensitivity medically necessary only if the one of the following diagnoses applies:
- E78.00 Pure hypercholesterolemia, unspecified
- E78.01 Familial hypercholesterolemia
- E78.1 Pure hyperglyceridemia
- E78.2 Mixed hyperlipidemia
- E78.3 Hyperchylomicronemia
- E78.4 Other hyperlipidemia
- I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
- Z74.09* Other reduced mobility
- Z78.9* Other specified health status
Please be aware that, as of April 2020, Medicare is rejecting payment for #507 C. Reactive Protein – Inflammation and #509 C. Relative Protein – High Sensitivity when both tests are ordered: “during the same session/date as a previously processed service for the patient”.
In regards to Vitamin D testing (CPT Code 82306), once a beneficiary has been shown to be vitamin D 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.
Ordering outside the guidelines/protocols as mentioned above will result in denial by Medicare for some or all of the testing. Coverage is not provided for TESTS PERFORMED AS PART OF A ROUTINE MEDICAL EXAMINATION OR FOR SCREENING PURPOSES. These tests are “Medicare Limited Coverage Tests” and can only be covered with specified diagnoses approved by Medicare. Aculabs has previously provided copies of this documentation to you as a reference.