L29262

 

PROSTATIC ACID PHOSPHATASE

 

02/02/2009

 

Indications and Limitations of Coverage and/or Medical Necessity

 

The acid phosphatase is indicated:

• To aid in the diagnosis and staging of metastatic cancer of the prostate.

• To monitor the effectiveness of treatment.

 

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

199.0 DISSEMINATED MALIGNANT NEOPLASM

199.1 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

 

 

Documentation 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.

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/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.

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

Treatment Logic

• 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.

 

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.

 

02/02/2009

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 2011 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 PROSTATIC ACID PHOSPHATASE