L29188

 

HEPATIC (LIVER) FUNCTION PANEL

 

01/12/2010

 

Indications and Limitations of Coverage and/or Medical Necessity

 

Indications

 

Medicare will consider a hepatic function panel medically necessary when performed for the following clinically indicated conditions:

• Signs and symptoms of liver disease (e.g.,

o jaundice,

o nausea accompanied with vomiting and/or weight loss,

o bright yellow urine, grey or pale colored stools,

o change of sleep patterns,

o vomiting of blood or the passing of blood in the stools,

o tiredness or loss of stamina,

o abdominal swelling caused by:

 an enlarged liver or an enlarged spleen or excess fluid in the abdomen [ascities],

 pain associated with the abdomen,

 increased water consumption and urination,

 progressive depression or lethargy

• Hematologic disturbances which are commonly associated with liver disease (e.g., coagulation disorders, anemia, thrombocytopenia)

• History of exposure to environmental toxins which may result in hepatotoxicity

• Patients under treatment with medications suspected or known to produce hepatotoxic effects. Commonly, instructions for use of such medications include manufacturer recommendations that frequent monitoring of liver function be performed while under treatment

• An abnormal value of any of the components of the panel; and/or

• A history of exposure to hepatitis.

 

Limitations

• Tests performed during annual physical examinations or other routine screening situations without signs, symptoms or illnesses which indicate medical necessity will result in denial as a non-covered benefit.

• Payment is made only for those tests in an automated profile that meet Medicare coverage rules.

o Where only some of the tests in a profile of tests are covered, payment cannot exceed the amount that would have paid if only the covered tests had been ordered.

 

CPT/HCPCS Codes

 

80076 HEPATIC FUNCTION PANEL

 

 

ICD-9 Codes that Support Medical Necessity

 

042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE

070.0 VIRAL HEPATITIS A WITH HEPATIC COMA

070.1 VIRAL HEPATITIS A WITHOUT HEPATIC COMA

070.20 VIRAL HEPATITIS B WITH HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA

070.21 VIRAL HEPATITIS B WITH HEPATIC COMA ACUTE OR UNSPECIFIED WITH HEPATITIS DELTA

070.22 CHRONIC VIRAL HEPATITIS B WITH HEPATIC COMA WITHOUT HEPATITIS DELTA

070.23 CHRONIC VIRAL HEPATITIS B WITH HEPATIC COMA WITH HEPATITIS DELTA

070.30 VIRAL HEPATITIS B WITHOUT HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA

070.31 VIRAL HEPATITIS B WITHOUT HEPATIC COMA ACUTE OR UNSPECIFIED WITH HEPATITIS DELTA

070.32 CHRONIC VIRAL HEPATITIS B WITHOUT HEPATIC COMA WITHOUT HEPATITIS DELTA

070.33 CHRONIC VIRAL HEPATITIS B WITHOUT HEPATIC COMA WITH HEPATITIS DELTA

070.41 ACUTE HEPATITIS C WITH HEPATIC COMA

070.42 HEPATITIS DELTA WITHOUT ACTIVE HEPATITIS B DISEASE WITH HEPATIC COMA HEPATITIS DELTA WITH HEPATITIS B CARRIER STATE

070.43 HEPATITIS E WITH HEPATIC COMA

070.44 CHRONIC HEPATITIS C WITH HEPATIC COMA

070.49 OTHER SPECIFIED VIRAL HEPATITIS WITH HEPATIC COMA

070.51 ACUTE HEPATITIS C WITHOUT MENTION OF HEPATIC COMA

070.52 HEPATITIS DELTA WITHOUT ACTIVE HEPATITIS B DISEASE OR HEPATIC COMA

070.53 HEPATITIS E WITHOUT HEPATIC COMA

070.54 CHRONIC HEPATITIS C WITHOUT HEPATIC COMA

070.59 OTHER SPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA

070.6 UNSPECIFIED VIRAL HEPATITIS WITH HEPATIC COMA

070.70 UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA

070.71 UNSPECIFIED VIRAL HEPATITIS C WITH HEPATIC COMA

070.9 UNSPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA

130.5 HEPATITIS DUE TO TOXOPLASMOSIS

151.0 MALIGNANT NEOPLASM OF CARDIA

151.1 MALIGNANT NEOPLASM OF PYLORUS

151.2 MALIGNANT NEOPLASM OF PYLORIC ANTRUM

151.3 MALIGNANT NEOPLASM OF FUNDUS OF STOMACH

151.4 MALIGNANT NEOPLASM OF BODY OF STOMACH

151.5 MALIGNANT NEOPLASM OF LESSER CURVATURE OF STOMACH UNSPECIFIED

151.6 MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED

151.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH

151.9 MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE

152.0 MALIGNANT NEOPLASM OF DUODENUM

152.1 MALIGNANT NEOPLASM OF JEJUNUM

152.2 MALIGNANT NEOPLASM OF ILEUM

152.3 MALIGNANT NEOPLASM OF MECKEL'S DIVERTICULUM

152.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SMALL INTESTINE

152.9 MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE

153.0 MALIGNANT NEOPLASM OF HEPATIC FLEXURE

153.1 MALIGNANT NEOPLASM OF TRANSVERSE COLON

153.2 MALIGNANT NEOPLASM OF DESCENDING COLON

153.3 MALIGNANT NEOPLASM OF SIGMOID COLON

153.4 MALIGNANT NEOPLASM OF CECUM

153.5 MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS

153.6 MALIGNANT NEOPLASM OF ASCENDING COLON

153.7 MALIGNANT NEOPLASM OF SPLENIC FLEXURE

153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE

153.9 MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE

154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION

154.1 MALIGNANT NEOPLASM OF RECTUM

154.2 MALIGNANT NEOPLASM OF ANAL CANAL

154.3 MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE

154.8 MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS

155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY

155.1 MALIGNANT NEOPLASM OF INTRAHEPATIC BILE DUCTS

155.2 MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY

156.0 MALIGNANT NEOPLASM OF GALLBLADDER

156.1 MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS

156.2 MALIGNANT NEOPLASM OF AMPULLA OF VATER

156.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF GALLBLADDER AND EXTRAHEPATIC BILE DUCTS

156.9 MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE

157.0 MALIGNANT NEOPLASM OF HEAD OF PANCREAS

157.1 MALIGNANT NEOPLASM OF BODY OF PANCREAS

157.2 MALIGNANT NEOPLASM OF TAIL OF PANCREAS

157.3 MALIGNANT NEOPLASM OF PANCREATIC DUCT

157.4 MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS

157.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS

157.9 MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

162.0 MALIGNANT NEOPLASM OF TRACHEA

162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS

162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG

162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG

162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG

162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG

162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

172.0 MALIGNANT MELANOMA OF SKIN OF LIP

172.1 MALIGNANT MELANOMA OF SKIN OF EYELID INCLUDING CANTHUS

172.2 MALIGNANT MELANOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL

172.3 MALIGNANT MELANOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE

172.4 MALIGNANT MELANOMA OF SKIN OF SCALP AND NECK

172.5 MALIGNANT MELANOMA OF SKIN OF TRUNK EXCEPT SCROTUM

172.6 MALIGNANT MELANOMA OF SKIN OF UPPER LIMB INCLUDING SHOULDER

172.7 MALIGNANT MELANOMA OF SKIN OF LOWER LIMB INCLUDING HIP

172.8 MALIGNANT MELANOMA OF OTHER SPECIFIED SITES OF SKIN

172.9 MELANOMA OF SKIN SITE UNSPECIFIED

174.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST

174.1 MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST

174.2 MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST

174.3 MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST

174.4 MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST

174.5 MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST

174.6 MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST

174.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST

174.9 MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE

175.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST

175.9 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST

197.7 MALIGNANT NEOPLASM OF LIVER SECONDARY

277.4 DISORDERS OF BILIRUBIN EXCRETION

286.9 OTHER AND UNSPECIFIED COAGULATION DEFECTS

287.5 THROMBOCYTOPENIA UNSPECIFIED

571.0 ALCOHOLIC FATTY LIVER

571.1 ACUTE ALCOHOLIC HEPATITIS

571.2 ALCOHOLIC CIRRHOSIS OF LIVER

571.3 ALCOHOLIC LIVER DAMAGE UNSPECIFIED

571.40 CHRONIC HEPATITIS UNSPECIFIED

571.41 CHRONIC PERSISTENT HEPATITIS

571.42 AUTOIMMUNE HEPATITIS

571.49 OTHER CHRONIC HEPATITIS

571.5 CIRRHOSIS OF LIVER WITHOUT ALCOHOL

571.6 BILIARY CIRRHOSIS

571.8 OTHER CHRONIC NONALCOHOLIC LIVER DISEASE

571.9 UNSPECIFIED CHRONIC LIVER DISEASE WITHOUT ALCOHOL

572.0 ABSCESS OF LIVER

572.1 PORTAL PYEMIA

572.2 HEPATIC ENCEPHALOPATHY

572.3 PORTAL HYPERTENSION

572.4 HEPATORENAL SYNDROME

572.8 OTHER SEQUELAE OF CHRONIC LIVER DISEASE

573.0 CHRONIC PASSIVE CONGESTION OF LIVER

573.1 HEPATITIS IN VIRAL DISEASES CLASSIFIED ELSEWHERE

573.2 HEPATITIS IN OTHER INFECTIOUS DISEASES CLASSIFIED ELSEWHERE

573.3 HEPATITIS UNSPECIFIED

573.4 HEPATIC INFARCTION

573.5 HEPATOPULMONARY SYNDROME

573.8 OTHER SPECIFIED DISORDERS OF LIVER

573.9 UNSPECIFIED DISORDER OF LIVER

574.00 CALCULUS OF GALLBLADDER WITH ACUTE CHOLECYSTITIS WITHOUT OBSTRUCTION

574.01 CALCULUS OF GALLBLADDER WITH ACUTE CHOLECYSTITIS WITH OBSTRUCTION

574.10 CALCULUS OF GALLBLADDER WITH OTHER CHOLECYSTITIS WITHOUT OBSTRUCTION

574.11 CALCULUS OF GALLBLADDER WITH OTHER CHOLECYSTITIS WITH OBSTRUCTION

574.20 CALCULUS OF GALLBLADDER WITHOUT CHOLECYSTITIS WITHOUT OBSTRUCTION

574.21 CALCULUS OF GALLBLADDER WITHOUT CHOLECYSTITIS WITH OBSTRUCTION

574.30 CALCULUS OF BILE DUCT WITH ACUTE CHOLECYSTITIS WITHOUT OBSTRUCTION

574.31 CALCULUS OF BILE DUCT WITH ACUTE CHOLECYSTITIS WITH OBSTRUCTION

574.40 CALCULUS OF BILE DUCT WITH OTHER CHOLECYSTITIS WITHOUT OBSTRUCTION

574.41 CALCULUS OF BILE DUCT WITH OTHER CHOLECYSTITIS WITH OBSTRUCTION

574.50 CALCULUS OF BILE DUCT WITHOUT CHOLECYSTITIS WITHOUT OBSTRUCTION

574.51 CALCULUS OF BILE DUCT WITHOUT CHOLECYSTITIS WITH OBSTRUCTION

574.60 CALCULUS OF GALLBLADDER AND BILE DUCT WITH ACUTE CHOLECYSTITIS WITHOUT OBSTRUCTION

574.61 CALCULUS OF GALLBLADDER AND BILE DUCT WITH ACUTE CHOLECYSTITIS WITH OBSTRUCTION

574.70 CALCULUS OF GALLBLADDER AND BILE DUCT WITH OTHER CHOLECYSTITIS WITHOUT OBSTRUCTION

574.71 CALCULUS OF GALLBLADDER AND BILE DUCT WITH OTHER CHOLECYSTITIS WITH OBSTRUCTION

574.80 CALCULUS OF GALLBLADDER AND BILE DUCT WITH ACUTE AND CHRONIC CHOLECYSTITIS WITHOUT OBSTRUCTION

574.81 CALCULUS OF GALLBLADDER AND BILE DUCT WITH ACUTE AND CHRONIC CHOLECYSTITIS WITH OBSTRUCTION

574.90 CALCULUS OF GALLBLADDER AND BILE DUCT WITHOUT CHOLECYSTITIS WITHOUT OBSTRUCTION

574.91 CALCULUS OF GALLBLADDER AND BILE DUCT WITHOUT CHOLECYSTITIS WITH OBSTRUCTION

575.0 ACUTE CHOLECYSTITIS

575.10 CHOLECYSTITIS UNSPECIFIED

575.11 CHRONIC CHOLECYSTITIS

575.12 ACUTE AND CHRONIC CHOLECYSTITIS

575.2 OBSTRUCTION OF GALLBLADDER

575.3 HYDROPS OF GALLBLADDER

575.4 PERFORATION OF GALLBLADDER

575.5 FISTULA OF GALLBLADDER

575.6 CHOLESTEROLOSIS OF GALLBLADDER

575.8 OTHER SPECIFIED DISORDERS OF GALLBLADDER

575.9 UNSPECIFIED DISORDER OF GALLBLADDER

576.0 POSTCHOLECYSTECTOMY SYNDROME

576.1 CHOLANGITIS

576.2 OBSTRUCTION OF BILE DUCT

576.3 PERFORATION OF BILE DUCT

576.4 FISTULA OF BILE DUCT

576.5 SPASM OF SPHINCTER OF ODDI

576.8 OTHER SPECIFIED DISORDERS OF BILIARY TRACT

576.9 UNSPECIFIED DISORDER OF BILIARY TRACT

578.0 HEMATEMESIS

578.1 BLOOD IN STOOL

780.79 OTHER MALAISE AND FATIGUE

782.4 JAUNDICE UNSPECIFIED NOT OF NEWBORN

789.01 ABDOMINAL PAIN RIGHT UPPER QUADRANT

789.05 ABDOMINAL PAIN PERIUMBILIC

789.06 ABDOMINAL PAIN EPIGASTRIC

789.1 HEPATOMEGALY

789.2 SPLENOMEGALY

789.59 OTHER ASCITES

790.4 NONSPECIFIC ELEVATION OF LEVELS OF TRANSAMINASE OR LACTIC ACID DEHYDROGENASE (LDH)

790.5 OTHER NONSPECIFIC ABNORMAL SERUM ENZYME LEVELS

791.4 BILIURIA

794.8 NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF LIVER

995.0 OTHER ANAPHYLACTIC REACTION

V01.79 CONTACT OR EXPOSURE TO OTHER VIRAL DISEASES

V42.7* LIVER REPLACED BY TRANSPLANT

V58.11 ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY

V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

V67.51 FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED

V87.39 CONTACT WITH AND (SUSPECTED) EXPOSURE TO OTHER POTENTIALLY HAZARDOUS SUBSTANCES

*According to the ICD-9-CM book, diagnosis code V42.7 is a secondary diagnosis codes and should not be billed as the primary diagnosis.

 

 

Documentation Requirements

• Documentation supporting the medical justification for components of the test billed must be contained in the patient’s medical records (e.g., office/progress notes).

• In addition, laboratory results of the tests ordered must be available upon request.

• If the provider of the service is other than the ordering/referring physician, the provider of the service must maintain hard copy documentation of the test results and interpretation, along with copies of the ordering/referring physician’s order for the studies.

• The physician must state the clinical indication/medical necessity for each test billed.

Treatment Logic

 

• Hepatic (liver) function can be measured in terms of serum enzyme activity such as alkaline phosphatase, transaminases, lactic dehydrogenase and serum concentrations of proteins, bilirubin, ammonia, clotting factors and lipids.

• Several of these tests may be helpful for the assessment and management of individuals with hepatic (liver) disease or injury and for monitoring the effects of medications and toxic material on liver function.

• The hepatic (liver) function panel consists of Albumin, serum; Bilirubin, total; Bilirubin, direct; alkaline phosphatase; transferase, alanine amino (ALT) (SGPT), transferase, aspartate amino (ALT) (SGOT); and protein, total.

 

Sources of Information and Basis for Decision

 

Detailed View: Safety labeling changes approved by FDA Center for Drug Evaluation and Research (CDER)(2003). Retrieved from website on 08/20/2000. http://www.fda.gov/med watch/SAFETY/2003/feb03.htm This source was used to identify drugs which may have adverse effects on liver function.

 

Food and Drug Administration Working Group (2000) Nonclinical assessment of potential hepatotoxicity in man. Retrieved from internet Sept. 2003 www.phrma.org/meetings/news/2000-12-11.13pdf This source was used to identify causes of liver toxicity in man.

 

Mosbys Drug Consult (2003) Mosby, Inc This source was used to identify drugs with potential hepatotoxic effects.

 

The Merck Manual of Diagnosis & Therapy, Sec 4, Ch 38, Clinical features of liver disease. Retrieved from online manual on September 3, 2003 This source was used to define signs and symptoms of liver disease.

 

U.S. Dept of Health and Human Services (2003) Guidance for industry pharmacokinetics in patients with impaired hepatic function: study, design, data, analysis and impact on dosing and labeling. Retrieved from internet 08/20/2003 http://www.fda.gov/eber/gdlns/imphep.pdf. This source was used to review methods recommended for determining drug dosage and monitoring for patients with impaired hepatic function.

 

01/12/2010

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

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 HEPATIC (LIVER) FUNCTION PANEL