Highmark Medicare Services

12102, 12202, 12302

MAC Part A & B

L27510

Parathormone (Parathyroid Hormone)

L27510

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title 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.

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 claim.

Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after N/A

N/A

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Parathyroid hormone (PTH), a polypeptide hormone produced in the parathyroid gland, along with Vitamin D, is the principal regulator of calcium and phosphorus homeostasis. The most important actions of PTH are (1) rapid mobilization of calcium and phosphate from bone and long-term acceleration of bone resorption, (2) increasing renal tubular reabsorption of calcium, (3) increasing intestinal absorption of calcium (mediated by an action on the metabolism of vitamin D), and (4) decreasing renal tubular reabsorption of phosphate. These actions account for most of the important clinical manifestations of PTH excess or deficiency.

Indications

Parathormone testing will be considered medically necessary for the following indications:

• Evaluation of patients with a combination of clinical signs and symptoms strongly suggesting hyperparathyroidism;
• Evaluating patients with a combination of clinical signs and symptoms of hypoparathyroidism;
• Evaluating patients with previously diagnosed hyperparathyroidism or hypoparathyroidism;
• Evaluating patients with ectopic parathyroid hormone-producing neoplasms;
• Evaluating and monitoring therapy of secondary hyperparathyroidism in chronic renal disease and/or status post renal transplantation;
• Immediate follow-up of patients who have undergone thyroidectomy and/or parathyroidectomy;
• Evaluating patients with an abnormal total or ionized calcium level;
• Distinguishing nonparathyroid from parathyroid causes of hypercalcemia;
• Evaluation of patients with a magnesium deficiency;
• Evaluation of patients with insufficient or excessive Vitamin D; and
• Evaluating a patient with osteoporosis to rule out parathormone involvement.

Limitations

PTH measurements should be interpreted in conjunction with a total calcium level. Ionized calcium may be helpful in addition to the total calcium.

Immunoradiometric (IRMA) or immunochemiluminescent (ICMA) assays for intact parathyroid hormone are the current tests of choice. Since displacement-type radioimmunoassays (RIAs) are not sufficiently sensitive to measure PTH levels in hypoparathyroidism, methods other than IRMA and ICMA will be considered not medically reasonable or necessary.

Recent injection of radioisotope may interfere with immunoradiometric assays for intact parathyroid hormone (IRMA).

PTH levels done in the absence of a change in the patient’s clinical status or serum calcium may be denied.

Screening tests, in the absence of associated signs, symptoms or complaints will be denied.

Lab Services

Contractors 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 claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. 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 Codes.

N/A

All those not listed under the “ICD-9 Codes that Support Medical Necessity” section of this policy.

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
   
4. The ordering physician should retain in the patient’s medical record, history and physical examination notes documenting evaluation and management of one of the Medicare covered conditions/diagnoses, with relevant clinical signs/symptoms or abnormal laboratory test results, appropriate to one of the covered indications.
   
   
5. The patient’s clinical record should further indicate changes/alterations in medications or management prescribed for the treatment of the patient.
   
   
6. There must be an attending/treating physician’s order for each test documented in the patient’s medical/clinical record.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

It is expected that PTH levels will be limited to 4 times per year; however, testing once per month may be warranted in patients with renal failure.  Medically necessary testing may be done more frequently in the early post operative period of a parathyroidectomy to monitor the success of surgery.  Use ICD-9-CM V67.00 to identify this situation.

It is not considered medically necessary for parathormone testing to be performed more than once (1) on any given day that it is performed.  Any claims for parathormone testing billed in excess of once on the day performed will be denied, unless this testing is being done in the operating room during surgery for parathyroid removal.  Use V77.99 to identify this situation.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27510

05/22/2008

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