CPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
82306 VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED
82652 VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED
Coverage Indications, Limitations, and/or Medical Necessity
Vitamin D is a hormone, synthesized by the skin, the liver, and then metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these services.
Vitamin D is called a “vitamin” because of its availability from an exogenous source, predominately from oily fish in the form of cholecalciferol, vitamin D3. Plant-based vitamin D is in the form of ergocalciferol, Vitamin D2. It is really a hormone, as it is synthesized by the skin, metabolized by the liver and converted by the kidney to an active hormone, calcitriol. Calcitriol in its classical action, absorbs calcium from the intestine, and promotes bone mineralization.
In the skin, 7-dehydrocholesterol is converted to vitamin D3 in response to sunlight, a process that is inhibited by sunscreen with a skin protection factor (SPF) of 8 or greater. Once in the blood, vitamin D2 or D3 from diet, or D3 from skin production are carried by an alpha-2-globulin, vitamin D binding protein, and are carried to the liver where they are hydroxylated to yield 25-hydroxyvitamin D (25OHD; calcidiol). 25OHD then is converted in the kidney to 1, 25(OH)2D (calcitriol) by the action of 25OHD-1-alpha hydroxylase (CYP27B1). The CYP27B1 in the kidney is regulated by nearly every hormone involved in calcium homeostasis, and its activity is stimulated by PTH, estrogen, calcitonin, prolactin, growth hormone, low calcium levels, and low phosphorus levels. Its activity is inhibited by calcitriol, thus providing the feedback loop that helps regulates its synthesis.
An excess of vitamin D is unusual, but may lead to hypercalcemia. Vitamin D deficiency may lead to a variety of disorders; the well-described is rickets in growing children or osteomalacia in adults. Evaluating the status of a patient’s vitamin D sufficiency is accomplished by measuring the level of 25-hydroxyvitamin D. Measurement of other metabolites is generally not necessary outside of several unusual metabolic bone disorders or in chronic kidney disease-mineral bone disorder (CKD-MBD).
Vitamin D (calciferol) comprises a group of fat soluble seco-sterols found naturally only in a few foods, such as fish-liver oils, fatty fish, mushrooms, egg yolks, and liver. The two major physiologically relevant forms of vitamin D are D 2 (ergocalciferol) and D 3 (cholecalciferol). Vitamin D 3 is photosynthesized in the skin of vertebrates by the action of solar ultraviolet (UV) B radiation on 7-dehydrocholesterol. Vitamin D 2 is produced by UV irradiation of ergosterol, which occurs in molds, yeast, and higher-order plants. Under conditions of regular sun exposure, dietary vitamin D intake is of minor importance. However, latitude, season, aging, sunscreen use, and skin pigmentation influence the production of vitamin D 3 by the skin.
The primary determinant for vitamin D deficiencies is 25 OH Vitamin D.
Indications:
Measurement of vitamin D levels is indicated for patients with:
chronic kidney disease stage III or greater;
osteoporosis;
osteomalacia;
osteopenia;
osteogenesis imperfecta;
osteosclerosis;
hypocalcemia;
hypercalcemia;
hypoparathyroidism;
hyperparathyroidism;
rickets;
vitamin D deficiency to monitor the efficacy of replacement therapy;
fibromyalgia;
granuloma forming diseases;
hypovitaminosis D;
hypervitaminosis D;
long term use of anticonvulsants or glucocorticoids and other medications known to lower -vitamin D levels;
malabsorption states;
obstructive jaundice;
cirrhosis;
psoriasis;
Paget’s disease of bone;
gastric bypass.
Measurement of 25 OH vitamin D levels is indicated for patients with:
certain chronic medications:
anti HIV
anticonvulsants
glucocorticoids
chronic kidney disease stage III or greater
cystic fibrosis
gastric bypass
hypoparathyroidism
hyperparathyroidism
hypocalcemia
hypercalcemia
inflammatory bowel disease
malabsorption and malnutrition
osteomalacia
osteopenia
osteoporosis
renal osteodystrophy
rickets
vitamin D deficiency on replacement therapy; to monitor the efficacy of treatment
Measurement of 1, 25 (OH) 2 vitamin D levels is indicated for patients with:
chronic kidney disease stage III or greater
hypercalcemia
renal osteodystrophy
Limitations:
For Medicare beneficiaries, screening tests are governed by statute (Social Security Act 1861 {nn}). Vitamin D testing may not be used for routine screening.
Assays of calcitriol need not be performed for each of the above conditions. The most common type of vitamin D deficiency is that of 25 OH Vitamin D.
The 1,25-dihydroxy form of vitamin D is generally only required to assist in the diagnosis of certain cases of rare endocrine disorders (primary hyperparathyroidism, hypothyroidism, pseudohypoparathyroidism), or for diagnosing and treating renal osteodystrophy and vitamin D-dependent and vitamin D resistant rickets, or in cases of unknown causes of hypercalcemia, including sarcoidosis. Level of both 25OHD and calcitriol are not needed as a panel for determining a patient’s vitamin D status or to monitor routine vitamin D replacement therapy for most diseases. It is expected that the medical record will justify the tests chosen for a particular disease entity, that all available components of 25 OH vitamin D and other metabolite levels will not be performed routinely on every patient and that supportive documentation for test choices will be available to the Contractor upon request.
This Contractor does not expect to receive billing for the various component sources of 25 OH vitamin D separately (such as stored D or diet derived D). Only one total 25 OH vitamin D assay (comprising the sum of both 25OHD2 and 25OHD3) will be considered for reimbursement on any particular day, if medically necessary, for the patient’s condition.
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 for this vitamin deficiency, although, generally, other parameters are measured. Annual testing of the vitamin D status may be appropriate depending upon the indication and other mitigating factors. Because there can be variability in individual 25OHD responses to supplemental vitamin D in high-risk individuals, the serum 25OHD levels could be retested after about 3 months of supplementation to confirm that the target 25OHD level has been reached. If the follow up test shows they have not yet reached the target level, the test can it be repeated in another 3 months until the target level is achieved.
Testing Methods
Several methods are available for measuring circulating concentrations of 25-OH-D. Medicare will cover laboratory tests that give practitioners accurate and reliable information. The method used to perform this testing should be validated.
Bill Type Codes:
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.
999x Not Applicable
Revenue Codes:
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
ICD-10 Codes that Support Medical Necessity
ICD-10 CODE DESCRIPTION
A15.0 Tuberculosis of lung
A15.4 Tuberculosis of intrathoracic lymph nodes
A15.5 Tuberculosis of larynx, trachea and bronchus
A15.6 Tuberculous pleurisy
A15.7 Primary respiratory tuberculosis
A15.8 Other respiratory tuberculosis
A17.0 Tuberculous meningitis
A17.1 Meningeal tuberculoma
A17.81 Tuberculoma of brain and spinal cord
A17.82 Tuberculous meningoencephalitis
A17.83 Tuberculous neuritis
A17.89 Other tuberculosis of nervous system
A17.9 Tuberculosis of nervous system, unspecified
A18.01 Tuberculosis of spine
A18.02 Tuberculous arthritis of other joints
A18.03 Tuberculosis of other bones
A18.09 Other musculoskeletal tuberculosis
A18.10 Tuberculosis of genitourinary system, unspecified
A18.11 Tuberculosis of kidney and ureter
A18.12 Tuberculosis of bladder
A18.13 Tuberculosis of other urinary organs
A18.14 Tuberculosis of prostate
A18.15 Tuberculosis of other male genital organs
A18.16 Tuberculosis of cervix
A18.17 Tuberculous female pelvic inflammatory disease
A18.18 Tuberculosis of other female genital organs
A18.2 Tuberculous peripheral lymphadenopathy
A18.31 Tuberculous peritonitis
A18.32 Tuberculous enteritis
A18.39 Retroperitoneal tuberculosis
A18.4 Tuberculosis of skin and subcutaneous tissue
A18.50 Tuberculosis of eye, unspecified
A18.51 Tuberculous episcleritis
A18.52 Tuberculous keratitis
A18.53 Tuberculous chorioretinitis
A18.54 Tuberculous iridocyclitis
A18.59 Other tuberculosis of eye
A18.6 Tuberculosis of (inner) (middle) ear
A18.7 Tuberculosis of adrenal glands
A18.81 Tuberculosis of thyroid gland
A18.82 Tuberculosis of other endocrine glands
A18.83 Tuberculosis of digestive tract organs, not elsewhere classified
A18.84 Tuberculosis of heart
A18.85 Tuberculosis of spleen
A18.89 Tuberculosis of other sites
A19.0 Acute miliary tuberculosis of a single specified site
A19.1 Acute miliary tuberculosis of multiple sites
A19.8 Other miliary tuberculosis
C22.0 Liver cell carcinoma
C22.1 Intrahepatic bile duct carcinoma
C22.2 Hepatoblastoma
C22.3 Angiosarcoma of liver
C22.4 Other sarcomas of liver
C22.7 Other specified carcinomas of liver
C22.8 Malignant neoplasm of liver, primary, unspecified as to type
C22.9 Malignant neoplasm of liver, not specified as primary or secondary
C23 Malignant neoplasm of gallbladder
C24.0 Malignant neoplasm of extrahepatic bile duct
C24.1 Malignant neoplasm of ampulla of Vater
C24.8 Malignant neoplasm of overlapping sites of biliary tract
C24.9 Malignant neoplasm of biliary tract, unspecified
C25.0 Malignant neoplasm of head of pancreas
C25.1 Malignant neoplasm of body of pancreas
C25.2 Malignant neoplasm of tail of pancreas
C25.3 Malignant neoplasm of pancreatic duct
C25.4 Malignant neoplasm of endocrine pancreas
C25.7 Malignant neoplasm of other parts of pancreas
C25.8 Malignant neoplasm of overlapping sites of pancreas
C25.9 Malignant neoplasm of pancreas, unspecified
C26.0 Malignant neoplasm of intestinal tract, part unspecified
C26.1 Malignant neoplasm of spleen
C26.9 Malignant neoplasm of ill-defined sites within the digestive system
D13.0 Benign neoplasm of esophagus
D13.1 Benign neoplasm of stomach
D13.2 Benign neoplasm of duodenum
D13.30 Benign neoplasm of unspecified part of small intestine
D13.39 Benign neoplasm of other parts of small intestine
D13.4 Benign neoplasm of liver
D13.5 Benign neoplasm of extrahepatic bile ducts
D13.6 Benign neoplasm of pancreas
D13.7 Benign neoplasm of endocrine pancreas
D13.9 Benign neoplasm of ill-defined sites within the digestive system
D86.0 Sarcoidosis of lung
D86.1 Sarcoidosis of lymph nodes
D86.2 Sarcoidosis of lung with sarcoidosis of lymph nodes
D86.3 Sarcoidosis of skin
D86.81 Sarcoid meningitis
D86.82 Multiple cranial nerve palsies in sarcoidosis
D86.83 Sarcoid iridocyclitis
D86.84 Sarcoid pyelonephritis
D86.85 Sarcoid myocarditis
D86.86 Sarcoid arthropathy
D86.87 Sarcoid myositis
D86.89 Sarcoidosis of other sites
E20.0 Idiopathic hypoparathyroidism
E20.8 Other hypoparathyroidism
E21.0 Primary hyperparathyroidism
E21.1 Secondary hyperparathyroidism, not elsewhere classified
E21.2 Other hyperparathyroidism
E21.4 Other specified disorders of parathyroid gland
