Article - Billing and Coding: Vitamin D Assay Testing (A57484)

CMS National Coverage PolicyTitle XVIII of Social Security Act, Section 1861 Act provides for payment of clinical laboratory services under Medicare Part B. Clinical laboratory services involve the biological, microbiological, serological, chemical, immunohematological, hematological, biophysical, cytological, pathological, or other examination of materials derived from the human body for the diagnosis, prevention, or treatment of a disease or assessment of a medical condition.Title XVIII of Social Security Act, Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Title XVIII of Social Security Act, Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.42 CFR part 493, laboratory services must meet all applicable requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA), as set forth. Section 1862(a)(1)(A) provides that Medicare payment may not be made for services that are not reasonable and necessary.42 CFR 410.32(a), clinical laboratory services must be ordered and used promptly by the physician who is treating the beneficiary.42 CFR 410.32(a) (3), or by a qualified nonphysician practitioner.CMS Pub 100-02,Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Care Services, 80.1  Clinical Laboratory Services and 80.6  Requirements for Ordering and Following Orders for Diagnostic Tests.CMS Pub. 100-04,Medicare Claims Processing Manual, Chapter 1- General Billing Requirements, Sections 60  Provider Billing of Non-covered Charges on Institutional Claims  60.1.1 - Basic Payment Liability Conditions.CMS Pub 100-04,Medicare Claims Processing Manual, Chapter 25  Completing and Processing the Form CMS-1450 Data Set, Section 75.5  From Locators 43-81, FL-67 Principal Diagnosis Codes.CMS Transmittal No, 857, effective date October 3, 2018 Change Request 10901 Local Coverage Determinations (LCDs) Implementation date January 8, 2019.Italicized font- represents CMS national language/wording copied directly from CMS Manuals or CMS Transmittals. Contractors are prohibited from changing national language/wording.Article TextThe billing and coding information in this article is dependent on the coverage indications, limitations and/or medical necessity described in the associated LCD Vitamin D Assay Testing.A. General Guidelines for claims submitted to MAC A/B contractors:Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.A claim submitted without a valid diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise, the symptoms prompting the performance of the test should be reported.For outpatient settings other than CORFs, references to "physicians" throughout this policy include non-physicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such non-physician practitioners, with certain exceptions, may certify, order, and establish the plan of care for Vitamin D Assay Testing services as authorized by State law.B. Billing Guidelines:Bill type codes only apply to providers billing these services to Part A. Bill type codes do not apply to physicians, other professionals, and suppliers who bill these services to Part B. (See CMS Publication 100-04,Medicare Claims Processing Manual,Chapter 25  Completing and Processing the Form CMS-1450 Data Set, Section 75.5  From Locators 43-81, FL-67 Principal Diagnosis Codes, for additional instructions.)All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim.Claims for Vitamin D Assay Testing services are payable under Medicare Part B in the following places of service: office (11), independent clinic (49), Federally Qualified health Center (50) and independent lab (81).