Parathyroid Hormone Testing
In November, each facility nurse manager, medical director, and administrator received a letter from Network 8 addressing bone disease quality indicators and providing facility-specific performance outcomes. After reviewing this report, several facilities contacted the Network with various concerns about frequent PTH testing.
While each facility is encouraged to develop and follow specific protocols for bone-disease management, tools such as the K/DOQI guidelines and prescribing information for bone disease-related medications are valuable resources for such. In the event that existing protocols appear to be outdated, we encourage review and revision as necessary. Frequency of PTH testing is addressed in both K/DOQI guidelines and prescribing information for Vitamin D analogues.
In regard to PTH testing, currently there is no National Coverage Determination (NCD), i.e., policy, by Medicare. When no NCD exists, local Medicare carriers may opt to create their own coverage policy, formerly known as a local medical review policy (LMRP). In November 2003, CMS issued a final rule directing carriers to issue local coverage determinations (LCD) rather than LMRPs. According to CMS, "The difference between LMRPs and LCDs is that LCDs consist only of ‘reasonable and necessary’ information, while LMRPs may also contain category or statutory provisions." All existing LMRPs will be converted to LCDs by December 31, 2005.
Furthermore, some clinics may be confused about composite rate lab tests. Tests included in the composite rate are covered by Medicare at the specified frequency using the ICD-9 code for chronic renal failure. Any test in the composite rate can be ordered at different frequency IF MEDICALLY JUSTIFIED, which would require a code other than chronic renal failure. As an aside, PTH testing is not included in the composite rate for laboratory tests.
Specifically speaking, neither Mississippi, Alabama, nor Tennessee has a LMRP or LCD for PTH testing. Some facilities may use out-of-state laboratories whose Medicare carrier DOES have a LMRP or LCD. Contact your laboratory service provider for further information regarding coverage if necessary.
Now for the bottom line — Medicare reimburses for ALL medically necessary laboratory tests. Medical necessity is defined by CMS as "services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member". Medical necessity is reflected by the ICD-9 code chosen if the code is not specific enough to reflect the need for the test, charges may be denied. Of note, as of October 1, 2004, a new code for secondary hyperparathyroidism of renal origin (588.81) was released.
Renal bone disease is a complex complication of ESRD and one that requires on-going monitoring and intervention for optimal outcomes. Understanding coverage issues for PTH monitoring can lead to better monitoring practices and improved bone disease outcomes. It is our hope that this information will be of benefit. Please call Network 8 if further concerns arise or if more information is needed.