L29262-LCD

Automated World Health

Local Coverage Determination (LCD) for Prostatic Acid Phosphatase (L29262)

Contractor Information

Contractor Name First Coast Service Options, Inc. opens in new window

Contractor Number 09102

Contractor Type MAC - Part B

LCD Information

Document Information

LCD ID Number L29262

LCD Title Prostatic Acid Phosphatase

Contractor's Determination Number 84066

Primary Geographic Jurisdiction opens in new window 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 02/02/2009

Original Determination Ending Date

Revision Effective Date

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, Medicare Claims Processing Manual, Chapter 16, Section 10

CMS Manual System, Pub. 100-8, Medicare Program Integrity Manual, Chapter 13, Section 13.1.3

Indications and Limitations of Coverage and/or Medical Necessity

Acid Phosphatase levels are used to aid in the diagnosis of metastatic cancer of the prostate gland and to follow the effectiveness of treatment. This laboratory procedure is rarely used except to confirm other procedures that are more specific and sensitive, (Prostate Specific Antigen) in diagnosis of Prostatic disease. It is known that elevated levels of acid phosphatase are seen in patients with prostate cancer that has metastasized beyond the capsule to other parts of the body, especially the bone. It is believed that once the carcinoma has spread, the prostate starts to release acid phosphatase, resulting in an increase in the blood level. The prostatic fraction procedure specifically measures the concentration of prostatic acid phosphatase secreted by cells of the prostate gland in contrast to the total enzyme activity, which is an indirect measurement.

The acid phosphatase is indicated to aid in the diagnosis and staging of metastatic cancer of the prostate and to monitor the effectiveness of treatment.

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.

999x Not Applicable

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.

99999 Not Applicable

CPT/HCPCS Codes

84066 PHOSPHATASE, ACID; PROSTATIC

ICD-9 Codes that Support Medical Necessity

185 MALIGNANT NEOPLASM OF PROSTATE

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

199.1 DISSEMINATED MALIGNANT NEOPLASM

199.2 OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE

222.2 BENIGN NEOPLASM OF PROSTATE

233.4 CARCINOMA IN SITU OF PROSTATE

236.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF PROSTATE

239.5 NEOPLASM OF UNSPECIFIED NATURE OF OTHER GENITOURINARY ORGANS

790.93 ELEVATED PROSTATE SPECIFIC ANTIGEN [PSA]

V10.46 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF PROSTATE

Diagnoses that Support Medical Necessity N/A

ICD-9 Codes that DO NOT Support Medical Necessity

All other diagnosis codes not listed as covered in the “ICD-9 Codes that Support Medical Necessity” section of this policy.

XX000 Not Applicable

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

Diagnoses that DO NOT Support Medical Necessity

All other diagnoses not listed as covered in the “ICD-9 Codes that Support Medical Necessity” section of this policy.

General Information

Documentations Requirements

Medical record documentation (e.g., office/progress notes) maintained by the ordering/referring physician[/nonphysician practitioner] 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/nonphysician practitioner, that provider must maintain documentation of test results and interpretation, along with copies of the ordering/referring physician/nonphysician practitioner’s order for the studies. The physician/nonphysician practitioner must state the clinical indication/medical necessity for the study in his/her 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

Knowles, D.F. (2005). Medical Encyclopedia: Prostatic acid phosphatase (PAP). In Medline Plus. Retrieved September 16, 2005, from http://www.nlm.nih.gov/medlineplus/ency/article/003467.htm

Bostwick, D.G., Qian, J., & Schlesinger, C. (2003). Contemporary pathology of prostate cancer [Electronic version]. Urologic Clinics of North America 30(2), 181-207.

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 advisory groups, which includes representatives from numerous societies.

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 12/04/2008

Revision History Number Original

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

Start Date of Notice Period:12/04/2008 Revised Effective Date:02/02/2009

LCR B2009-

December 2008 Bulletin

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

For Florida (00590) this LCD (L29262) replaces LCD L6189 as the policy in notice. This document (L29262) is effective on 02/02/2009.

Reason for Change