Preterm delivery is a serious complication of pregnancy and a contributing
factor in up to 70% of all neonatal deaths and many long-term childhood
disabilities. Fetal Fibronectin is a reliable diagnostic test for the
identification of women who are at risk of preterm labor. Preterm labor is
often misdiagnosed, leading to billions of dollars in health care expenses
annually from unnecessary hospital admissions, pharmacy and diagnostic
procedures.
The Adzea fFn test detects fetal fibronectin protein, a clinically
proven, direct biochemical marker for assessing the risk of preterm
delivery in pregnant women. The use of fFn has been heralded by the OB/GYN
community as the first safe, non-invasive and objective tool to identify
risk for preterm delivery.
The rapid fFn test employs a single-use dry chemistry immunoassay
procedure. Results are available within 1 hour of collection. The CPT code
for the procedure is 82731. Specimens must be collected using the Adeza
Fetal Fibronectin kits. Specimens that are not tested immediately after
collection must be stored refrigerated at 2 to 8 degrees C and assayed
within three days of collection to avoid degradation of the analyte. Do
not expose to temperatures beyond what is recommended. Frozen specimens
are stable for twelve months.
Testing will be available at both Avera McKennan and Avera St. Luke's
Laboratories soon. Please contact the client services department at these
facilities for collection kits and further details.
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MEDICARE REIMBURSEMENT FOR TROPONIN I CLARIFICATIONS.
Some facilities have experienced denials of Medicare claims for
troponin and CK testing performed on the same day. The September Newsline
should clarify billing matters on these tests. The latest information we
have is that troponins and CKs will be allowed on the same day.
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GIARDIA ANTIGEN.
The ova and parasite exam has traditionally been ordered when
evaluating patients with diarrhea. Other than Giardia lamblia, intestinal
parasites are extremely rare in the patient population of this area. For
example, since the institution of Giardia antigen testing at Avera
McKennan Hospital Laboratory in January of 1993, no intestinal parasites
other than Giardia lamblia have been identified in patients that
did not meet the O&P criteria. Giardia antigen testing is highly
sensitive and specific. For most patients, being evaluated for diarrhea,
Giardia antigen is the most cost-effective test. In patients who are
recent immigrants, have traveled outside the U.S. or for which there is
other reason to suspect a parasite other than Giardia lamblia the
ova and parasite exam may be appropriate.
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AVERA HEALTH HOSPITALS RECEIVE JCAHO REACCREDITATION.
Avera Sacred Heart, Avera Queen of Peace, Avera St. Luke's and Avera
McKennan were recently re-accredited by JCAHO, the largest national
hospital accrediting organization. All four hospitals received praise for
their compassion and respect for patients, emphasis on quality improvement
and competent employees.
Congratulations to all the hard working employees of these sister
hospitals!
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LOCAL MEDICAL REVIEW REMINDERS FOR PHYSICIANS.
SUBJECT: LIPID PROFILE/CHOLESTEROL TESTING.
Description: Lipoproteins are a class of heterogenous particles of
varying sizes and densities, containing lipid and protein. These
lipoproteins include cholesterol esters and free cholesterol,
triglycerides, phospholipids, and A, C, and E apoproteins.
In most individuals, an elevated blood cholesterol constitutes an
increased risk of developing coronary artery disease. Scientific evidence
has established that lowering elevated blood cholesterol (specifically LDL)
will reduce the risk of heart attack due to coronary heart disease (CHD).
Elevated levels of total -cholesterol and low-density lipoprotein
cholesterol (LDL-C) are associated with increased risk, as are low levels
of high-density lipoprotein cholesterol (HDL-C). Levels may be decreased
by several factors, including diet and decreasing fat in the diet.
Total cholesterol comprises all the cholesterol found in various
lipoproteins.
There are three groups at risk based on cholesterol levels:
Desirable risk: Total cholesterol <200
LDL Cholesterol <130
Borderline risk: Total cholesterol 200-239
LDL cholesterol 130-159
High risk: Total cholesterol >240
LDL cholesterol >1 60
There are three groups at risk based on triglyceride levels:
Triglyceride of >599 mgm/dl = Abnormal high
Triglyceride of <250 mg/dl = Normal
Triglyceride of 250-500 mgm/dl = Has two times the risk of
cardiovascular disease.
Indications and Limitations of Coverage: Testing will be covered at
a combined frequency of up to three times a year for dietary therapy and
four times a year for drug therapy. Testing beyond this must be documented
in the patient's medical record to support medical necessity.
Reasons for Non-Coverage: Any diagnosis which is not listed in the
covered ICD-9 diagnosis section of model policy #96.24.
Under all other conditions, lipid profile/cholesterol testing is
considered screening and is therefore not covered. A family history alone
does not indicate medical necessity. Routine screening and prophylactic
testing are not allowed for payment purposes in the Medicare program.
These are non-covered services which means that while such use may
represent good medical practice, this type of testing cannot be reimbursed
by Medicare. Only those services which directly relate to disease, injury
or malfunctioning body parts-are covered by Medicare.
Measured LDL (83721) should only be used with documented triglycerides
>400.
The addition of an HDL cholesterol to a chemistry profile to provide
the basic three components of a lipid protein (total cholesterol,
triglycerides, and HDL) is acceptable if performed as part of coronary
artery evaluation or ongoing monitoring of vascular disease.
Most follow-up may be done with total cholesterol (83465).
Triglycerides (84478) may be obtained if this lipid fraction is also
elevated or if the patient is put on drugs (i.e. thiazide diuretics, beta
blockers, estrogens, glucocorticoids, and tamoxifen) which may raise the
triglyceride level. Need for a full lipid profile (80061) will depend on
the clinical circumstances of the individual patient.
Lipid profile (80061) and hepatic panel (80058) testing will be
reimbursed with severe psoriasis which has not responded to conventional
therapy and for which the retinoid estretinate has been prescribed and who
have developed hyperlipidemia or hepatic toxicity. Specific examples
include erythrodermia and generalized pustular type, and psoriasis
associated with arthritis. These two panels will be allowed at a frequency
in keeping with medical necessity and appropriate medical practice
acceptable to the carrier’s medical review.
After the initial definition of the cholesterol abnormality, follow-up
testing during the treatment of hypercholesterol is usually done with a
total cholesterol. Follow-up testing with a lipid profile would be
appropriate at less frequent intervals (refer to indications and
limitations section for frequency). For example, in patients with
borderline high cholesterol who are not being treated or in patients who
are stable on dietary and/or drug therapy, performing a lipid profile
yearly would be reasonable.
In patients with significantly elevated cholesterol levels who are
being aggressively managed with drug therapy, a lipid profile may be
reasonable every 3-4 months until the clinical condition has stabilized.
More frequent use of lipid profiles or use of other lipid fraction tests
to follow the course of treatment would need to be individually justified.
Documentation: Submission of ICD-9 codes other than those listed as
covered in policy #96.24 must be supported by written medical necessity
documentation. Claim submissions of diagnosis outside this guideline must
have accompanying written medical necessity documentation. The ordering
physician must clearly document in the patient's clinical record
conformity to this policy and/or support the medical necessity for
deviation. The treatment plan, if the patient is being treated for those
conditions listed, must be in the patient's medical record. Direct LDL
measurement will only be reimbursed with accompanying documentation of
triglycerides >400. Note: These guidelines apply to
laboratory claims reimbursed by Medicare Part A (paid by an
intermediary) and claims reimbursed by Medicare Part B (paid by a
carrier).
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SUBJECT: FOLIC ACID, SERUM CPT CODE: 82746
Description: Folic acid, also known as folate, is a B-complex vitamin
which serves as a carrier of onecarbon groups in many metabolic reactions.
As a tetra-hydrofolate, it is required in the synthesis and catabolism of
several amino acids, the formation of creatine and choline, the
methylation of RNAS, the synthesis of purines, and the synthesis of DNA.
Folic acid deficiency is usually nutritional in origin, and results in
megaloblastic anemia. Unlike vitamin Bl 2 deficiency, folic acid
deficiency does not cause neuropathy.
Indications and Limitations of Coverage: Serum folic acid testing
is indicated when a macrocytic anemia is suspected using blood indices,
especially when the Mean Corpuscular Volume (MCV) is above 1 00 fl.
Serum folic acid levels are generally indicated in the evaluation of
megaloblastic anemias whose cause is unknown, and in the setting of
nutritional deficiency status, alcoholism, pregnancy, and malabsorption.
Therapy with certain drugs, especially dehydrofolate reductase inhibitors
such as methotrexate and trimthoprim, can result in folic acid deficiency
and may be an indication to determine serum folic acid levels.
Except in malabsorptive states where periodic serum folic acid
determinations may help in monitoring disease severity, sequential testing
of folic acid is usually unnecessary, as response to treatment can be
ascertained through increase in hemoglobin, hematrocrit or decrease in
macrocytosis/megaloblastosis.
Reasons for Denial: Medicare does not cover routine screening
studies.
Non-covered ICD-9 codes: Any diagnostic code not listed in the covered
ICD-9 diagnosis section of model policy #97.13.
Documentation Requirements: Medical records should document signs
and symptoms to substantiate medical necessity.
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SUBJECT- VITAMIN B12 (CYANOCOBALAMIN) CHEMISTRY TEST.