L28902-LCD

Automated World Health

Local Coverage Determination (LCD) for Magnesium (L28902)

Contractor Information

Contractor Name

First Coast Service Options, Inc.

Contractor Number 09101

Contractor Type

MAC - Part A

LCD Information

Document Information

LCD ID Number L28902

LCD Title Magnesium

Contractor's Determination Number A83735

Primary Geographic Jurisdiction Florida

Oversight Region Region IV

AMA CPT/ADA CDT Copyright Statement

CPT only copyright 2002-2011 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Original Determination Effective Date

For services performed on or after 02/16/2009

Original Determination Ending Date

Revision Effective Date

For services performed on or after 10/01/2011

Revision Ending Date

CMS National Coverage Policy

Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See §1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: CMS Manual System, Pub. 100-4, Chapter 8, Section 50.1

Indications and Limitations of Coverage and/or Medical Necessity

Magnesium is an important activator ion, participating in the function of many enzymes involved in phosphate transfer reactions. Most of the magnesium found within the body exists intracellularly, and since most of it is bound to adenosine triphosphate, this electrolyte is critical in nearly all metabolic processes and most organ functions. Magnesium exerts physiologic effects on the nervous system resembling those of calcium, acting directly upon the myoneural junction. Furthermore, magnesium acts as a cofactor that modifies the activity of many enzymes. Carbohydrate, protein, and nucleic acid metabolism depend on magnesium. Excretion of magnesium is via the kidney, and altered concentration of magnesium in the plasma usually provokes an associated alteration of calcium and potassium. The normal plasma concentration of magnesium is 1.5-2.5 meq/L, with about one-third bound to protein and two-thirds existing as free cation.

Medicare will consider magnesium testing to be medically necessary under any of the following circumstances:

• In the presence of signs or symptoms of hypomagnesemia, which include weakness, muscle cramping, irritability, tetany, electrocardiographic changes, delirium, anorexia, nausea, and vomiting. Conditions which can produce these signs and symptoms include, but are not limited to the following:

- cardiac arrhythmias

- malabsorption syndromes

- alcoholism

- parenteral alimentation with inadequate magnesium content

- diarrhea

- diabetic ketoacidosis

- diuretic therapy

- hyperaldosteronism

- hypoparathyroidism

- hyperthyroidism

- chronic renal disease

- prolonged I.V. therapy

- prolonged nasogastric suction

- cisplatinum therapy

- aminoglycoside toxicity

- amphotericin toxicity

• In the presence of signs or symptoms of hypermagnesemia, including muscle weakness, mental obtundation, and confusion. Weakness and a fall in blood pressure are evident on examination. There may be respiratory muscle paralysis or cardiac arrest. Conditions which can produce these signs and symptoms include, but are not limited to the following:

- adrenal insufficiency

- renal insufficiency

- ingestion of magnesium-containing drugs, such as antacids and laxatives

- rhabdomyolysis

Coding Information

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.

012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient

014x Hospital - Laboratory Services Provided to Non-patients 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient

072x Clinic - Hospital Based or Independent Renal Dialysis Center 085x Critical Access Hospital

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.

0301 Laboratory - Chemistry

CPT/HCPCS Codes 83735 MAGNESIUM

ICD-9 Codes that Support Medical Necessity

242.00 - 242.91

250.10 - 250.13

250.20 - 250.23

250.30 - 250.33

250.40 - 250.43

250.50 - 250.53

250.60 - 250.63

250.70 - 250.73

TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM

DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], UNCONTROLLED

DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], UNCONTROLLED

DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], UNCONTROLLED

DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.80 - 250.83

252.00 - 252.08

DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

HYPERPARATHYROIDISM, UNSPECIFIED - OTHER HYPERPARATHYROIDISM

252.1 HYPOPARATHYROIDISM

252.8 OTHER SPECIFIED DISORDERS OF PARATHYROID GLAND

253.6 OTHER DISORDERS OF NEUROHYPOPHYSIS

255.10 - 255.14

HYPERALDOSTERONISM, UNSPECIFIED - OTHER SECONDARY ALDOSTERONISM

255.41 GLUCOCORTICOID DEFICIENCY

255.42 MINERALOCORTICOID DEFICIENCY

259.3 ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED

260 KWASHIORKOR

261 NUTRITIONAL MARASMUS

262 OTHER SEVERE PROTEIN-CALORIE MALNUTRITION

263.0 MALNUTRITION OF MODERATE DEGREE

263.8 OTHER PROTEIN-CALORIE MALNUTRITION

275.2 DISORDERS OF MAGNESIUM METABOLISM

275.40 - 275.49

UNSPECIFIED DISORDER OF CALCIUM METABOLISM - OTHER DISORDERS OF CALCIUM METABOLISM

276.2 ACIDOSIS

276.4 MIXED ACID-BASE BALANCE DISORDER

276.50 - 276.52

VOLUME DEPLETION, UNSPECIFIED - HYPOVOLEMIA

276.7 HYPERPOTASSEMIA

276.8 HYPOPOTASSEMIA

293.1 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE

293.2 SUBACUTE DELIRIUM

303.90 - 303.93

305.00 - 305.03

OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE UNSPECIFIED DRINKING BEHAVIOR - OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE IN REMISSION

NONDEPENDENT ALCOHOL ABUSE UNSPECIFIED DRINKING BEHAVIOR - NONDEPENDENT ALCOHOL ABUSE IN REMISSION

307.1 ANOREXIA NERVOSA

307.51 BULIMIA NERVOSA

307.52 PICA

333.2 MYOCLONUS

333.3 TICS OF ORGANIC ORIGIN

410.00 - 410.92

ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE

424.0 MITRAL VALVE DISORDERS

427.0 - 427.89 opens PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - OTHER SPECIFIED CARDIAC

in new window

DYSRHYTHMIAS

428.0 CONGESTIVE HEART FAILURE UNSPECIFIED

458.0 - 458.8 opens

in new window ORTHOSTATIC HYPOTENSION - OTHER SPECIFIED HYPOTENSION

536.2 PERSISTENT VOMITING

569.87 VOMITING OF FECAL MATTER

577.0 - 577.9 opens

in new window ACUTE PANCREATITIS - UNSPECIFIED DISEASE OF PANCREAS

579.3 OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION

579.8 OTHER SPECIFIED INTESTINAL MALABSORPTION

584.5 - 584.9

ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS - ACUTE KIDNEY FAILURE, UNSPECIFIED

CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED

585.1 - 585.9

588.81 - 588.89

SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) - OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION

593.81 VASCULAR DISORDERS OF KIDNEY

643.00 - 643.83

646.80 - 646.84

MILD HYPEREMESIS GRAVIDARUM UNSPECIFIED AS TO EPISODE OF CARE - OTHER

VOMITING COMPLICATING PREGNANCY ANTEPARTUM

OTHER SPECIFIED COMPLICATIONS OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE - OTHER SPECIFIED POSTPARTUM COMPLICATIONS

728.87 MUSCLE WEAKNESS (GENERALIZED)

728.88 RHABDOMYOLYSIS

728.89 OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA

763.81 -

763.89 opens in new window

ABNORMALITY IN FETAL HEART RATE OR RHYTHM BEFORE THE ONSET OF LABOR - OTHER

SPECIFIED COMPLICATIONS OF LABOR AND DELIVERY AFFECTING FETUS OR NEWBORN

780.1 COMA

780.2 TRANSIENT ALTERATION OF AWARENESS

780.09 ALTERATION OF CONSCIOUSNESS OTHER

780.2 SYNCOPE AND COLLAPSE

780.31 - 780.39

FEBRILE CONVULSIONS (SIMPLE), UNSPECIFIED - OTHER CONVULSIONS

781.0 ABNORMAL INVOLUNTARY MOVEMENTS

781.7 TETANY

783.0 ANOREXIA

785.0 TACHYCARDIA UNSPECIFIED

785.50 - 785.59

787.04

SHOCK UNSPECIFIED - OTHER SHOCK WITHOUT TRAUMA

NAUSEA WITH VOMITING - BILIOUS EMESIS

787.91 DIARRHEA

790.6 OTHER ABNORMAL BLOOD CHEMISTRY

794.31 NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)

794.4 NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF KIDNEY

796.1 ABNORMAL REFLEX

799.4 CACHEXIA

940.0 - 949.5

CHEMICAL BURN OF EYELIDS AND PERIOCULAR AREA - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE UNSPECIFIED SITE WITH LOSS OF A BODY PART

958.4 TRAUMATIC SHOCK

995.29 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

997.1 CARDIAC COMPLICATIONS NOT ELSEWHERE CLASSIFIED

998.00 - 998.09

POSTOPERATIVE SHOCK, UNSPECIFIED - POSTOPERATIVE SHOCK, OTHER

V42.0* KIDNEY REPLACED BY TRANSPLANT

V42.7* LIVER REPLACED BY TRANSPLANT

V56.0 AFTERCARE INVOLVING EXTRACORPOREAL DIALYSIS

V56.8 AFTERCARE INVOLVING OTHER DIALYSIS

V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY V58.69* LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

* According to the ICD-9-CM book, diagnosis codes V42.0 V42.7 and V58.69 are secondary diagnosis codes and should not be billed as the primary diagnosis.

Note: Renal dialysis facilities (72x) should report a diagnosis code of 585.6 for submission of claims.

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity N/A

General Information

Documentations Requirements

Medical record documentation (i.e., office notes/progress notes) maintained by the ordering/referring physician must indicate the medical necessity for performing the test. Additionally, a copy of the test results should be maintained in the medical records.

If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of test results and interpretation, along with copies of the ordering/referring physician’s order for the study. The physician must state the clinical indication/medical necessity for the study in the order

for the test.

Appendices

Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they

may be subject to review for medical necessity.

Sources of Information and Basis for Decision

Ford, M.D., Delaney, K.A., Ling, L.J., Erickson, T. (2001) Clinical Toxicology (1st ed.) Philadelphia: WB Saunders. This source used to gain knowledge of the uses of serum magnesium laboratory studies and interpretations.

Gums, J.G. (2004) Magnesium in cardiovascular and other disorders. American Journal of Health-System Pharmacy 61(15) 1569-76. This source identifies pathological processes which may be caused by magnesium deficiency.

Liebscher D.H., Liebscher D.E. (2004) About the misdiagnosis of magnesium deficiency.[Abstract] Journal of the American College of Nutrition, 23, 6. This source discusses what is considered a normal serum magnesium values and its inadequacy in identifying magnesium deficiency.

Noble, John (Ed). (2001) Textbook of Primary Care Medicine (3rd ed.) St. Louis, MO: Mosby. This source used provide knowledge of the metabolic characteristics of magnesium, the pathophysiology of magnesium deficiency and its management.

Stalnikowicz, R. (2003) The significance of routine serum magnesium determination in the ED. American Journal of Emergency Medicine, 21(5) 444-7. This source identified the frequency of magnesium deficiency in patients presenting to the emergency room and the significance of determining serum magnesium levels.

Advisory Committee Meeting Notes This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this policy was developed in cooperation

with advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 10/01/2009

Revision History Number 2

Revision History Explanation Revision Number: 2 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2011 Revised Effective Date:10/01/2011

LCR A2011-078

September 2011 Connection

Explanation of Revision: Annual 2012 ICD-9-CM Update. Deleted diagnosis code 998.0 and replaced it with diagnosis code range 998.00-998.09. The effective date of this revision is based on date of service.

Revision Number:1

Start Date of Comment Period:N/A Start Date of Notice Period:10/01/2009 Revised Effective Date: 10/01/2009

LCR A2009-081

September 2009 Bulletin

Explanation of Revision: Annual 2010 ICD-9-CM Update. Added new diagnosis codes 569.87 and 787.04. Descriptor revised for diagnosis range 584.5-584.9. The effective date of this revision is based on date of service

Revision Number:Original

Start Date of Comment Period:N/A Start Date of Notice Period:12/04/2008 Revised Effective Date:02/16/2009

LCR A2009-

December 2008 Bulletin

This LCD consolidates and replaces all previous policies and publications on this subject by the fiscal intermediary predecessors of First Coast Service Options, Inc. (COSVI and FCSO).

For Florida (00090) this LCD (L28902) replaces LCD L1432 as the policy in notice. This document (L28902) is effective on 02/16/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update. 8/1/2010 - The description for Bill Type Code 12 was changed

8/1/2010 - The description for Bill Type Code 13 was changed 8/1/2010 - The description for Bill Type Code 14 was changed 8/1/2010 - The description for Bill Type Code 21 was changed 8/1/2010 - The description for Bill Type Code 22 was changed 8/1/2010 - The description for Bill Type Code 23 was changed 8/1/2010 - The description for Bill Type Code 72 was changed 8/1/2010 - The description for Bill Type Code 85 was changed

8/1/2010 - The description for Revenue code 0301 was changed

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update. 08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

Reason for Change