L28995-LCD

Automated World Health

Local Coverage Determination (LCD) for Total Calcium (L28995)

Contractor Information

Contractor Name First Coast Service Options, Inc.

Contractor Number

09101

Contractor Type

MAC - Part A

LCD Information

Document Information

LCD ID Number L28995

LCD Title Total Calcium

Contractor's Determination Number A82310

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 10/01/2009

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. 100-02, Medicare Benefit Policy, Chapter 11, Section 30.2-30.2.1; and 70.2

CMS Manual System, Pub. 100-03, Medicare National Coverage Determination, Chapter 1, Part 3, Section 190.10

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 8, Section 50.1; and 60-60.1 CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 23, Section 40

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.1.3

Indications and Limitations of Coverage and/or Medical Necessity

The serum calcium test is used to evaluate parathyroid function and calcium metabolism by directly measuring the total amount of calcium in the blood. About 50% of blood calcium is ionized; the rest is protein bound (with albumin). The serum calcium level is a measurement of both. The normal adult serum calcium level is between 8.5-10.5mg/dl.

Medicare will consider a calcium test medically reasonable and necessary for the following conditions:

• Evaluation of patients with clinical signs and symptoms of hypercalcemia. Signs and symptoms of hypercalcemia include, but are not limited to the following:

nausea and vomiting

prominent skeletal muscle weakness Anorexia

polyuria, nocturia, polydipsia

Constipation stupor abdominal pain coma dehydration

ECG changes/prolongation of QT interval lethargy

confusion

flank pain due to renal calculi

Conditions in which a serum calcium test may be medically necessary for hypercalcemia include, but are not limited to, the following: hyperparathyroidism; malignancies; adrenal insufficiency; acromegaly; hypervitaminosis D; immobilization; and drugs (e.g., thiazide diuretics, calcium salts, etc.).

• Evaluation of patients with clinical signs and symptoms of hypocalcemia. Signs and symptoms of hypocalcemia include, but are not limited to, the following:

-muscle twitching

-ECG changes/shortened QT interval Chvostek’s sign (facial muscle spasm) arrhythmias

-Trousseau’s sign (carpopedal spasm) bronchospasm

-tetany dysphagia

-muscle cramping

-diplopia and photophobia seizure activity

-anxiety malaise

-unexplained dementia, depression, & psychosis circumforal and peripheral numbness and tingling

Conditions in which a serum calcium test may be medically reasonable and necessary for hypocalcemia include, but are not limited to, the following: hypoparathyroidism; hypoalbuminemia; renal failure; pancreatitis; vitamin D deficiency; severe malnutrition and malabsorption; septic shock; and drugs (e.g., anticonvulsants, heparin, laxatives, loop diuretics, magnesium salts, and etc.).

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

Disorders of calcium metabolism are initially evaluated with measurements of serum phosphorus, albumin, chloride, magnesium, potassium, total protein, parathyroid hormone levels, and often a 24-hour urine calcium level.

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

82310 CALCIUM; TOTAL

ICD-9 Codes that Support Medical Necessity

135 SARCOIDOSIS

140.0 - 208.92

209.00 - 209.03

209.10 - 209.17

209.20 -

MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - UNSPECIFIED LEUKEMIA, IN RELAPSE

MALIGNANT CARCINOID TUMOR OF THE SMALL INTESTINE, UNSPECIFIED PORTION - MALIGNANT CARCINOID TUMOR OF THE ILEUM

MALIGNANT CARCINOID TUMOR OF THE LARGE INTESTINE, UNSPECIFIED PORTION - MALIGNANT CARCINOID TUMOR OF THE RECTUM

MALIGNANT CARCINOID TUMOR OF UNKNOWN PRIMARY SITE - MALIGNANT CARCINOID

209.29 TUMOR OF OTHER SITES

209.30 - MALIGNANT POORLY DIFFERENTIATED NEUROENDOCRINE CARCINOMA, ANY SITE -

209.36 MERKEL CELL CARCINOMA OF OTHER SITES

252.00 - 252.08 opens in new HYPERPARATHYROIDISM, UNSPECIFIED - OTHER HYPERPARATHYROIDISM

252.1 HYPOPARATHYROIDISM

255.41 GLUCOCORTICOID DEFICIENCY

255.42 MINERALOCORTICOID DEFICIENCY

260 - 269.9 KWASHIORKOR - UNSPECIFIED NUTRITIONAL DEFICIENCY

275.41 HYPOCALCEMIA

275.42 HYPERCALCEMIA

275.49 OTHER DISORDERS OF CALCIUM METABOLISM

276.0 - 276.9 HYPEROSMOLALITY AND/OR HYPERNATREMIA - ELECTROLYTE AND FLUID DISORDERS NOT

ELSEWHERE CLASSIFIED

278.4 HYPERVITAMINOSIS D

293.1 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE

293.2 SUBACUTE DELIRIUM

293.83 MOOD DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE

298.9 UNSPECIFIED PSYCHOSIS

300.00 - 300.09 ANXIETY STATE UNSPECIFIED - OTHER ANXIETY STATES

368.13 VISUAL DISCOMFORT

368.2 DIPLOPIA

427.0 - 427.9 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - CARDIAC DYSRHYTHMIA UNSPECIFIED

519.11 ACUTE BRONCHOSPASM

519.19 OTHER DISEASES OF TRACHEA AND BRONCHUS

564.00 - 564.09 UNSPECIFIED CONSTIPATION - OTHER CONSTIPATION

577.1 ACUTE PANCREATITIS

577.2 CHRONIC PANCREATITIS

579.0 - 579.9 CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION

580.0 - 580.9 ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS -ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

581.0 - 581.9 NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS -NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

582.0 - 582.9 CHRONIC GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

583.0 - 583.9 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY

584.5 - 584.9 ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS - ACUTE KIDNEY FAILURE,

585.1 - 585.9 UNSPECIFIED CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED

586 RENAL FAILURE UNSPECIFIED

587 RENAL SCLEROSIS UNSPECIFIED

588.0 - 588.9 RENAL OSTEODYSTROPHY - UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION

592.0 CALCULUS OF KIDNEY

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

729.82 CRAMP OF LIMB

733.90 DISORDER OF BONE AND CARTILAGE UNSPECIFIED

780.01 COMA

780.09 ALTERATION OF CONSCIOUSNESS OTHER

780.1 HALLUCINATIONS

780.39 OTHER CONVULSIONS

780.79 OTHER MALAISE AND FATIGUE

781.0 ABNORMAL INVOLUNTARY MOVEMENTS

781.7 TETANY

782.0 DISTURBANCE OF SKIN SENSATION

783.0 ANOREXIA

783.5 POLYDIPSIA

785.59 OTHER SHOCK WITHOUT TRAUMA

787.01 - 787.04

787.20 - NAUSEA WITH VOMITING - BILIOUS EMESIS

787.29 DYSPHAGIA, UNSPECIFIED - OTHER DYSPHAGIA

788.42 POLYURIA

788.43 NOCTURIA

789.00 ABDOMINAL PAIN UNSPECIFIED SITE

E934.2* ANTICOAGULANTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E936.3* OTHER AND UNSPECIFIED ANTICONVULSANTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE

E943.3* OTHER CATHARTICS INCLUDING INTESTINAL ATONIA DRUGS 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

* According to the ICD-9-CM book, diagnosis codes E934.2, E936.3, E943.3, E944.4 and E944.5 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 maintained by the performing provider must clearly indicate the medical necessity of the service being billed. In addition, documentation that the service was performed must be included in the patient’s medical record. This information is normally found in the office/progress notes, hospital notes, and/or procedure report.

Documentation should support the criteria for coverage as set forth in the “Indications and Limitations of Coverage and/or Medical Necessity” section of this policy.

Appendices

Utilization Guidelines In accordance with national Medicare coverage policy, serum calcium laboratory tests are routinely covered at a frequency of once per month for hemodialysis, intermittent peritoneal dialysis, continuous cycling peritoneal dialysis, and hemofiltration beneficiaries. Serum calcium laboratory tests are routinely covered at a frequency of once per month if furnished to (CAPD) patients in a certified setting. A diagnosis of ESRD alone is not sufficient medical evidence to warrant coverage of additional tests. Services performed at a greater frequency are covered if medically necessary and used in timely medical decision making.

Sources of Information and Basis for Decision

AACE/AAES Task Force. (2005). The Diagnosis and Management of Primary Hyperparathyroidism {Electronic version}. American Journal of Gastroenterology 11(1), 49-54.

Anderson, D.M., Keith, J., Novak, P.D., & Elliott, M.A. (2002). Mosby’s Medical Dictionary, Sixth Edition. St. Louis: Mosby, Inc.

Beers, M., & Berkow, R. (1999-2005). The Merck Manual of Diagnosis and Therapy, Seventeenth Edition, Centennial Edition. Retrieved June 7, 2005, from http://www.merck.com/mrkshared/mmanual/home.jsp

Advisory Committee Meeting Notes This Local Coverage Determination (LCD) does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the contractor, this LCD was developed in cooperation with the 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 1

Revision History Explanation 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 209.31-209.36 and 787.04. Revised the descriptor for diagnosis code 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 (L28995) replaces LCD L1587 as the policy in notice. This document (L28995) 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

Reason for Change ICD9 Addition/Deletion