L28984

 

SERUM PHOSPHORUS

 

10/01/2010

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Medicare will consider serum phosphorus testing medically reasonable and necessary under either of the two following circumstances:

• Evaluation of patients with signs and symptoms of hypophosphatemia.

o Patients with mild hypophosphatemia usually have no clinical manifestations.

o Clinical findings below usually occur when the phosphate deficit is severe:

 Anorexia.

 Hypercaliuria.

 Nausea.

 Osteomalacia.

 Muscle weakness and soreness.

 Rhabdomyolysis.

 Bone pain.

 Encephalopathy.

 Apprehension.

 Seizures.

 Confusion.

 Hemolysis.

 Paresthesias.

 Platelet dysfunction.

 Mental obtundation.

 Thrombocytopenia.

o Conditions in which serum phosphorus testing may be medically reasonable and necessary include, but are not limited to, the following which are related to hypophosphatemia:

 Decreased phosphate ingestion or absorption:

• Malnutrition: alcoholism, starvation.

• Vitamin D deficiency.

• Malabsorption syndromes.

• Hyperalimentation without phosphate supplements.

 Increased utilization or consequence of metabolism:

• Pregnancy.

• Recovery from malnutrition or diabetic ketoacidosis: insulin and glucose therapy.

• Respiratory alkalosis: salicylate poisoning, gram-negative bacteremia.

• Lactate, sodium bicarbonate, or sodium chloride infusions.

• Absorption by bone following parathyroidectomy.

 Excess losses of phosphate:

• Dialysis.

• Diuretic therapy.

• Primary hyperparathyroidism.

• Renal tubular defects: congenital, after renal transplant, toxic, and diuretic phase following acute renal failure or burns.

• Oral antacid therapy.

 Hypomagnesemia.

• Evaluation of patients with hyperphosphatemia. Patients with hyperphosphatemia usually have no clinical symptoms per se.

o Symptoms may arise, however, from underlying conditions. Some signs of hyperphosphatemia can include, but are not limited to, the following:

 Serum phosphorus level greater than 4.5 mg/dl on two fasting blood levels.

 Skeletal lesions on x-ray.

 Elevation of serum creatinine and alkaline phosphatase.

o Conditions in which serum phosphate testing may be medically reasonable and necessary include, but are not limited to, the following which are related to hyperphosphatemia:

 Excess phosphate from exogenous sources:

• Ingestion of dairy products.

• Ingestion of phosphate salts or use of phosphate enemas in patients with renal disease.

• Hypervitaminosis D.

• Sarcoidosis.

o Excess phosphate from endogenous sources:

 Metabolic or respiratory acidosis.

 Skeletal lesion, local: myeloma, Paget’s disease, metastatic carcinoma.

 Skeletal lesion, diffuse:

• Prolonged skeletal immobilization.

• Severe hyperparathyroidism secondary to renal disease.

 Phosphate release from tissue destruction or ischemia: irradiation or chemotherapy, hemolysis, lactic acidosis.

o Impaired excretion of phosphate:

 Renal disease.

 Hypoparathyroidism.

• Even though a patient has a condition stated above, it is not expected that a serum phosphorus test be performed frequently for stable chronic symptoms that are associated with that disease.

• Tests useful in the differential diagnosis include repeat serum phosphorus, alkaline phosphatase, calcium, parathyroid hormone, and skeletal x-ray.

• In accordance with national Medicare coverage policy, serum phosphate laboratory tests are routinely covered at a frequency of once per month for hemodialysis, intermittent peritoneal dialysis, continuous cycling peritoneal dialysis, and hemofiltration beneficiaries.

o Services performed at a greater frequency are covered if medically necessary and used in timely medical decision making.

 

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.

 

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

14x Hospital - Laboratory Services Provided to Non-patients

21x Skilled Nursing - Inpatient (Including Medicare Part A)

22x Skilled Nursing - Inpatient (Medicare Part B only)

23x Skilled Nursing - Outpatient

72x Clinic - Hospital Based or Independent Renal Dialysis Center

85x 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

 

 

84100 PHOSPHORUS INORGANIC (PHOSPHATE);

 

ICD-9 Codes that Support Medical Necessity

 

135 SARCOIDOSIS

170.0 MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE

170.1 MALIGNANT NEOPLASM OF MANDIBLE

170.2 MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX

170.3 MALIGNANT NEOPLASM OF RIBS STERNUM AND CLAVICLE

170.4 MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB

170.5 MALIGNANT NEOPLASM OF SHORT BONES OF UPPER LIMB

170.6 MALIGNANT NEOPLASM OF PELVIC BONES SACRUM AND COCCYX

170.7 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB

170.8 MALIGNANT NEOPLASM OF SHORT BONES OF LOWER LIMB

170.9 MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

203.00 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION

203.01 MULTIPLE MYELOMA IN REMISSION

203.02 MULTIPLE MYELOMA, IN RELAPSE

238.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS

252.00 HYPERPARATHYROIDISM, UNSPECIFIED

252.01 PRIMARY HYPERPARATHYROIDISM

252.02 SECONDARY HYPERPARATHYROIDISM, NON-RENAL

252.08 OTHER HYPERPARATHYROIDISM

260 KWASHIORKOR

261 NUTRITIONAL MARASMUS

262 OTHER SEVERE PROTEIN-CALORIE MALNUTRITION

263.0 MALNUTRITION OF MODERATE DEGREE

263.1 MALNUTRITION OF MILD DEGREE

263.2 ARRESTED DEVELOPMENT FOLLOWING PROTEIN-CALORIE MALNUTRITION

263.8 OTHER PROTEIN-CALORIE MALNUTRITION

263.9 UNSPECIFIED PROTEIN-CALORIE MALNUTRITION

268.0 RICKETS ACTIVE

268.1 RICKETS LATE EFFECT

268.2 OSTEOMALACIA UNSPECIFIED

268.9 UNSPECIFIED VITAMIN D DEFICIENCY

275.2 DISORDERS OF MAGNESIUM METABOLISM

275.3 DISORDERS OF PHOSPHORUS METABOLISM

275.40 UNSPECIFIED DISORDER OF CALCIUM METABOLISM

275.41 HYPOCALCEMIA

275.42 HYPERCALCEMIA

275.49 OTHER DISORDERS OF CALCIUM METABOLISM

276.0 HYPEROSMOLALITY AND/OR HYPERNATREMIA

276.1 HYPOSMOLALITY AND/OR HYPONATREMIA

276.2 ACIDOSIS

276.3 ALKALOSIS

276.4 MIXED ACID-BASE BALANCE DISORDER

276.50 VOLUME DEPLETION, UNSPECIFIED

276.51 DEHYDRATION

276.52 HYPOVOLEMIA

276.61 TRANSFUSION ASSOCIATED CIRCULATORY OVERLOAD

276.69 OTHER FLUID OVERLOAD

276.7 HYPERPOTASSEMIA

276.8 HYPOPOTASSEMIA

276.9 ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED

278.4 HYPERVITAMINOSIS D

278.8 OTHER HYPERALIMENTATION

283.9 ACQUIRED HEMOLYTIC ANEMIA UNSPECIFIED

287.0 ALLERGIC PURPURA

287.1 QUALITATIVE PLATELET DEFECTS

287.2 OTHER NONTHROMBOCYTOPENIC PURPURAS

287.30 PRIMARY THROMBOCYTOPENIA,UNSPECIFIED

287.31 IMMUNE THROMBOCYTOPENIC PURPURA

287.32 EVANS’ SYNDROME

287.33 CONGENITAL AND HEREDITARY THROMBOCYTOPENIC PURPURA

287.39 OTHER PRIMARY THROMBOCYTOPENIA

287.41 POSTTRANSFUSION PURPURA

287.49 OTHER SECONDARY THROMBOCYTOPENIA

287.5 THROMBOCYTOPENIA UNSPECIFIED

287.8 OTHER SPECIFIED HEMORRHAGIC CONDITIONS

287.9 UNSPECIFIED HEMORRHAGIC CONDITIONS

293.0 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE

293.1 SUBACUTE DELIRIUM

298.9 UNSPECIFIED PSYCHOSIS

348.30 ENCEPHALOPATHY UNSPECIFIED

348.31 METABOLIC ENCEPHALOPATHY

348.39 OTHER ENCEPHALOPATHY

403.01 HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

403.11 HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.02 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.03 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.12 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

404.13 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE

579.0 CELIAC DISEASE

579.1 TROPICAL SPRUE

579.2 BLIND LOOP SYNDROME

579.3 OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION

579.4 PANCREATIC STEATORRHEA

579.8 OTHER SPECIFIED INTESTINAL MALABSORPTION

579.9 UNSPECIFIED INTESTINAL MALABSORPTION

580.0 ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS

580.4 ACUTE GLOMERULONEPHRITIS WITH LESION OF RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS

580.81 ACUTE GLOMERULONEPHRITIS IN DISEASES CLASSIFIED ELSEWHERE

580.89 ACUTE GLOMERULONEPHRITIS WITH OTHER SPECIFIED PATHOLOGICAL LESION IN KIDNEY

580.9 ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

581.0 NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS

581.1 NEPHROTIC SYNDROME WITH LESION OF MEMBRANOUS GLOMERULONEPHRITIS

581.2 NEPHROTIC SYNDROME WITH LESION OF MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS

581.3 NEPHROTIC SYNDROME WITH LESION OF MINIMAL CHANGE GLOMERULONEPHRITIS

581.81 NEPHROTIC SYNDROME IN DISEASES CLASSIFIED ELSEWHERE

581.89 OTHER NEPHROTIC SYNDROME WITH SPECIFIED PATHOLOGICAL LESION IN KIDNEY

581.9 NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

582.0 CHRONIC GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS

582.1 CHRONIC GLOMERULONEPHRITIS WITH LESION OF MEMBRANOUS GLOMERULONEPHRITIS

582.2 CHRONIC GLOMERULONEPHRITIS WITH LESION OF MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS

582.4 CHRONIC GLOMERULONEPHRITIS WITH LESION OF RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS

582.81 CHRONIC GLOMERULONEPHRITIS IN DISEASES CLASSIFIED ELSEWHERE

582.89 OTHER CHRONIC GLOMERULONEPHRITIS WITH SPECIFIED PATHOLOGICAL LESION IN KIDNEY

582.9 CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

583.0 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS

583.1 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF MEMBRANOUS GLOMERULONEPHRITIS

583.2 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF MEMBRANOPROLIFERATIVE GLOMERULONEPHRITIS

583.4 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS

583.6 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF RENAL CORTICAL NECROSIS

583.7 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF RENAL MEDULLARY NECROSIS

583.81 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC IN DISEASES CLASSIFIED ELSEWHERE

583.89 OTHER NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH SPECIFIED PATHOLOGICAL LESION IN KIDNEY

583.9 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

584.5 ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS

584.6 ACUTE KIDNEY FAILURE WITH LESION OF RENAL CORTICAL NECROSIS

584.7 ACUTE KIDNEY FAILURE WITH LESION OF RENAL MEDULLARY [PAPILLARY] NECROSIS

584.8 ACUTE KIDNEY FAILURE WITH OTHER SPECIFIED PATHOLOGICAL LESION IN KIDNEY

584.9 ACUTE KIDNEY FAILURE, UNSPECIFIED

585.1 CHRONIC KIDNEY DISEASE, STAGE I

585.2 CHRONIC KIDNEY DISEASE, STAGE II (MILD)

585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)

585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)

585.5 CHRONIC KIDNEY DISEASE, STAGE V

585.6 END STAGE RENAL DISEASE

585.9 CHRONIC KIDNEY DISEASE, UNSPECIFIED

586 RENAL FAILURE UNSPECIFIED

587 RENAL SCLEROSIS UNSPECIFIED

588.0 RENAL OSTEODYSTROPHY

588.1 NEPHROGENIC DIABETES INSIPIDUS

588.81 SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN)

588.89 OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION

588.9 UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION

646.90 UNSPECIFIED COMPLICATION OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE

728.87 MUSCLE WEAKNESS (GENERALIZED)

728.88 RHABDOMYOLYSIS

728.89 OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA

728.9 UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA

729.1 MYALGIA AND MYOSITIS UNSPECIFIED

731.0 OSTEITIS DEFORMANS WITHOUT BONE TUMOR

733.90 DISORDER OF BONE AND CARTILAGE UNSPECIFIED

753.9 UNSPECIFIED CONGENITAL ANOMALY OF URINARY SYSTEM

780.39 OTHER CONVULSIONS

782.0 DISTURBANCE OF SKIN SENSATION

783.0 ANOREXIA

787.02 NAUSEA ALONE

790.6 OTHER ABNORMAL BLOOD CHEMISTRY

790.7 BACTEREMIA

793.0 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD

793.7 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF MUSCULOSKELETAL SYSTEM

799.21 NERVOUSNESS

799.22 IRRITABILITY

799.51 ATTENTION OR CONCENTRATION DEFICIT

799.52 COGNITIVE COMMUNICATION DEFICIT

799.54 PSYCHOMOTOR DEFICIT

799.55 FRONTAL LOBE AND EXECUTIVE FUNCTION DEFICIT

965.1 POISONING BY SALICYLATES

990 EFFECTS OF RADIATION UNSPECIFIED

995.84 ADULT NEGLECT (NUTRITIONAL)

E858.5* ACCIDENTAL POISONING BY WATER MINERAL AND URIC ACID METABOLISM DRUGS

E933.3* ALKALIZING AGENTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E943.0* ANTACIDS AND ANTIGASTRIC SECRETION DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E944.0 MERCURIAL DIURETICS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E944.1 PURINE DERIVATIVE DIURETICS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E944.2 CARBONIC ACID ANHYDRASE INHIBITORS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E944.3 SALURETICS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E944.4 OTHER DIURETICS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E944.5 ELECTOLYTIC CALORIC AND WATER-BALANCE AGENTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E944.6 OTHER MINERAL SALTS NOT ELSEWHERE CLASSIFIED CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E944.7* URIC ACID METABOLISM DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

V45.89* OTHER POSTSURGICAL STATUS

* According to the ICD-9-CM book, Diagnosis codes E858.5, E933.3, E943.0, E944.0-E944.7 and V45.89 are secondary diagnosis codes and should not be billed as the primary diagnosis.

 

Documentation Requirements

• Medical record documentation (e.g., office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity for performing the test.

o 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 studies.

o The physician must state the clinical indication/medical necessity for the study in his order for the test.

 

Utilization Guidelines

• Routine serum phosphate laboratory tests are covered at a frequency of once per month for hemodialysis, intermittent peritoneal dialysis, continuous cycling peritoneal dialysis, and hemofiltration beneficiaries.

o These tests are included in the facility’s composite rate and may not be billed separately to the Medicare program.

o Services performed at a greater frequency than specified are separately billable if medically necessary.

o A diagnosis of ESRD alone is not sufficient medical evidence to warrant coverage of additional tests.

• It is expected that these services would be performed as indicated by current medical literature and/or standards of practice.

o When services are performed in excess of established parameters, they may be subject to review for medical necessity.

 

Treatment Logic

• Phosphorus levels are determined by calcium metabolism, parathyroid hormone, and to a lesser degree by intestinal absorption.

• Normal serum phosphorus is 2.5-4.5 mg/dl.

• Serum phosphate levels help to detect endocrine, skeletal, and calcium disorders, and aid in the diagnosis of renal disorders and acid-base imbalance.

 

Sources of Information and Basis for Decision

 

Anderson, D.M. (2002). Mosby’s medical dictionary (6th ed.). St. Louis, MO: Mosby.

 

Beers, M. H., Berkow, R. (Ed.), (2005). Water, Electrolyte, Mineral, and Acid-Base Metabolism. The Merck Manual, Sec. 2, Ch. 12. Retrieved July 29, 2005, from www.merck.com/mrksearch/SearchServlet?.

 

FCSO LCD 29278, Serum Phosphorus, 10/01/2010. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Rodriguez-Benot, A. (2005). Mild hyperphosphatemia and mortality in hemodialysis patients [Abstract]. American Journal of Kidney Disease, 46(1): 68-77.

 

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2012 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.

 

 

CMS LCD L28984 SERUM PHOSPHORUS