L29278-LCD

Automated World Health

Local Coverage Determination (LCD) for Serum Phosphorus (L29278)

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 L29278

LCD Title

Serum Phosphorus

Contractor's Determination Number 84100

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

For services performed on or after 10/01/2010

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 other wise 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 30.2.1

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

190.10

CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 16, Sections 10; 10.2; 50.5.1;

90.1, and 90.2

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

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.

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

1. Evaluation of patients with signs and symptoms of hypophosphatemia. Patients with mild hypophosphatemia usually have no clinical manifestations. 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

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

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

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

• 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

• 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. 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.

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

84100 PHOSPHORUS INORGANIC (PHOSPHATE);

ICD-9 Codes that Support Medical Necessity

135 SARCOIDOSIS

170.0 - 170.9 opens in new window

MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE - MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

203.00 -

203.02 opens in new window

MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MULTIPLE MYELOMA, IN RELAPSE

238.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS 252.00 -

252.08 opens in new window

HYPERPARATHYROIDISM, UNSPECIFIED - OTHER HYPERPARATHYROIDISM

260 KWASHIORKOR

261 NUTRITIONAL MARASMUS

262 OTHER SEVERE PROTEIN-CALORIE MALNUTRITION

263.0 - 263.9 opens in new window 268.0 - 268.9 opens

MALNUTRITION OF MODERATE DEGREE - UNSPECIFIED PROTEIN-CALORIE MALNUTRITION

in new window RICKETS ACTIVE - UNSPECIFIED VITAMIN D DEFICIENCY

275.2 DISORDERS OF MAGNESIUM METABOLISM

275.3 DISORDERS OF PHOSPHORUS METABOLISM

275.40 -275.49 opens in new window

276.0 - 276.9 opens in new window

UNSPECIFIED DISORDER OF CALCIUM METABOLISM - OTHER DISORDERS OF CALCIUM METABOLISM

HYPEROSMOLALITY AND/OR HYPERNATREMIA - ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED

278.4 HYPERVITAMINOSIS D

278.8 OTHER HYPERALIMENTATION

283.9 ACQUIRED HEMOLYTIC ANEMIA UNSPECIFIED

287.0 - 287.9 opens

in new window ALLERGIC PURPURA - UNSPECIFIED HEMORRHAGIC CONDITIONS

293.1 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE

293.2 SUBACUTE DELIRIUM

298.9 UNSPECIFIED PSYCHOSIS

348.30 -

348.39 opens in new window

ENCEPHALOPATHY UNSPECIFIED - 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

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

404.3 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 - 579.9 opens in new window CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION

580.0 - 580.9 opens in new window 581.0 - 581.9 opens in new window

582.0 - 582.9 opens in new window

583.0 - 583.9 opens in new window

584.5 - 584.9 opens in new window 585.1 - 585.9 opens in new window

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

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

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

ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS - ACUTE KIDNEY FAILURE, UNSPECIFIED

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

586 RENAL FAILURE UNSPECIFIED

587 RENAL SCLEROSIS UNSPECIFIED

588.0 - 588.9 opens in new window

RENAL OSTEODYSTROPHY - 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 -

E944.7* opens in new window

MERCURIAL DIURETICS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE - 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.

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 (e.g., office/progress notes) maintained by the ordering/referring physician 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, 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. The physician must state the clinical indication/medical necessity for the study in his order

for the test.

Appendices

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. These tests are included in the facility’s composite rate and may not be billed separately to the Medicare program. Services performed at a greater frequency than specified are separately billable if medically necessary. 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. 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

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?.

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

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 10/01/2010

Revision History Number 2

Revision History Explanation Revision Number:2 Start Date of Comment Period:N/A

Start Date of Notice Period:10/01/2010 Revised Effective Date: 10/01/2010

LCR B2010-071

September 2010 Update

Explanation of Revision: Annual 2011 ICD-9-CM Update. Added new diagnosis codes 799.51, 799.52, 799.54, and

799.55 and descriptors. The effective date of this revision is based on date of service.

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 B2009-098

September 2009 Update

Explanation of Revision: Annual 2010 ICD-9-CM Update. Added new diagnosis codes 799.21 and 799.22. Revised descriptor for diagnosis codes 584.5-584.9, 793.0 and 793.7. Deleted diagnosis code 799.2. 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:02/02/2009

LCR B2009-044FL

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 (L29278) replaces LCD L6494 as the policy in notice. This document (L29278) is effective on 02/02/2009.

08/08/2009 - This policy was updated by the ICD-9 2009-2010 Annual Update. 09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

Reason for Change