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Contractor Information

Contractor Name ^{back to top}

Palmetto GBA
Contractor Number ^{back to top}
00380
Contractor Type ^{back to top}
FI

LCD Information

LCD ID Number ^{back to top}

L10354

LCD Title ^{back to top}
Serum Protein

Contractor's Determination Number ^{back to top}
01A-0002-L

AMA CPT / ADA CDT Copyright Statement ^{back to top}
CPT codes, descriptions and other data only are copyright 2009 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 National Coverage Policy ^{back to top}
Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Chapter 11, §§30.2.1, 70.2, 70.3 CMS Manual System, Pub. 100-02, Medicare Benefit Policy, Transmittal 35, dated June 3, 2005, Change Request 3802 CMS Manual System, Pub. 100-08, Medicare Program Integrity, Transmittal 63, dated January 23, 2004, Change Request 3010

Primary Geographic Jurisdiction ^{back to top}
South Carolina

Oversight Region ^{back to top}
Region IV

Original Determination Effective Date ^{back to top}
For services performed on or after 08/01/2001

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 12/04/2008

Revision Ending Date ^{back to top}
09/30/2009

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Protein testing aids in the diagnosis of some inflammatory and neoplastic states, nephrotic syndrome, liver diseases, and immune dysfunctions. Protein testing aids in the evaluation of nutritional states and osmotic pressures in edematous and malnourished patients. Symptoms of hyperproteinemia and hypoproteinemia may arise from such underlying conditions as listed in the *“ICD-9-CM Codes That Support Medical Necessity”* section of this policy. Palmetto GBA will consider serum protein testing reasonable and necessary under either of the following conditions: 1. Evaluation of beneficiaries with conditions related to hyperproteinemia 2. Evaluation of beneficiaries with conditions related to hypoproteinemia This policy does not apply to serum protein determinations performed as part of an organ/disease panel.

Coding Information

Bill Type Codes: ^{back to top}

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.

12x	Hospital-inpatient or home health visits (Part B only)
13x	Hospital-outpatient (HHA-A also) (under OPPS 13X must be used for ASC claims submitted for OPPS payment -- eff. 7/00)
14x	Non-Patient Laboratory Specimens
18x	Hospital-swing beds
21x	SNF-inpatient, Part A
22x	SNF-inpatient or home health visits (Part B only)
23x	SNF-outpatient (HHA-A also)
71x	Clinic-rural health
72x	Clinic-hospital based or independent renal dialysis facility
73x	Clinic-independent provider based FQHC (eff 10/91)
85x	Special facility or ASC surgery-rural primary care hospital (eff 10/94)

Revenue Codes: ^{back to top}

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.

0300	Laboratory-general classification
0301	Laboratory-chemistry

CPT/HCPCS Codes ^{back to top}

84155	PROTEIN, TOTAL, EXCEPT BY REFRACTOMETRY; SERUM, PLASMA OR WHOLE BLOOD
84160	PROTEIN, TOTAL, BY REFRACTOMETRY, ANY SOURCE
84165	PROTEIN; ELECTROPHORETIC FRACTIONATION AND QUANTITATION, SERUM

ICD-9 Codes that Support Medical Necessity ^{back to top}

001.0 - 009.0	CHOLERA DUE TO VIBRIO CHOLERAE - INFECTIOUS COLITIS ENTERITIS AND GASTROENTERITIS
010.00 - 016.06	PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - TUBERCULOSIS OF KIDNEY TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
030.0 - 030.9	LEPROMATOUS LEPROSY (TYPE L) - LEPROSY UNSPECIFIED
070.0 - 070.9	VIRAL HEPATITIS A WITH HEPATIC COMA - UNSPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA
085.0	LEISHMANIASIS VISCERAL (KALA-AZAR)
127.2	STRONGYLOIDIASIS
135	SARCOIDOSIS
200.00 - 200.08	RETICULOSARCOMA UNSPECIFIED SITE - RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.10 - 200.18	LYMPHOSARCOMA UNSPECIFIED SITE - LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.20 - 200.28	BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE - BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
200.30 - 200.38	MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.40 - 200.48	MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.50 - 200.58	PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.60 - 200.68	ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.70 - 200.78	LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
200.80 - 200.88	OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.00 - 202.08	NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.70 - 202.78	PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
202.80 - 202.88	OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.90 - 202.98	OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES
203.00	MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.01	MULTIPLE MYELOMA IN REMISSION
203.02	MULTIPLE MYELOMA, IN RELAPSE
203.10	PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.11	PLASMA CELL LEUKEMIA IN REMISSION
203.12	PLASMA CELL LEUKEMIA, IN RELAPSE
203.80	OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
203.81	OTHER IMMUNOPROLIFERATIVE NEOPLASMS IN REMISSION
203.82	OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE
204.00	ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.01	LYMPHOID LEUKEMIA ACUTE IN REMISSION
204.02	ACUTE LYMPHOID LEUKEMIA, IN RELAPSE
204.10	CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.11	LYMPHOID LEUKEMIA CHRONIC IN REMISSION
204.12	CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE
204.20	SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.21	LYMPHOID LEUKEMIA SUBACUTE IN REMISSION
204.22	SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE
204.80	OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.81	OTHER LYMPHOID LEUKEMIA IN REMISSION
204.82	OTHER LYMPHOID LEUKEMIA, IN RELAPSE
204.90	UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
204.91	UNSPECIFIED LYMPHOID LEUKEMIA IN REMISSION
204.92	UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE
208.00	ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.01	LEUKEMIA OF UNSPECIFIED CELL TYPE ACUTE IN REMISSION
208.02	ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
208.10	CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.11	LEUKEMIA OF UNSPECIFIED CELL TYPE CHRONIC IN REMISSION
208.12	CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
208.20	SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.22	SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
208.80	OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.81	OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE IN REMISSION
208.82	OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
208.90	UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
208.91	UNSPECIFIED LEUKEMIA IN REMISSION
208.92	UNSPECIFIED LEUKEMIA, IN RELAPSE
238.6	NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS
238.77	POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD)
242.00 - 242.91	TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM
244.0 - 244.9	POSTSURGICAL HYPOTHYROIDISM - UNSPECIFIED ACQUIRED HYPOTHYROIDISM
260 - 263.9	KWASHIORKOR - UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
273.0 - 273.9	POLYCLONAL HYPERGAMMAGLOBULINEMIA - UNSPECIFIED DISORDER OF PLASMA PROTEIN METABOLISM
275.42	HYPERCALCEMIA
275.49	OTHER DISORDERS OF CALCIUM METABOLISM
275.5	HUNGRY BONE SYNDROME
276.50	VOLUME DEPLETION, UNSPECIFIED
276.51	DEHYDRATION
276.52	HYPOVOLEMIA
277.30 - 277.39	AMYLOIDOSIS, UNSPECIFIED - OTHER AMYLOIDOSIS
279.00 - 279.09	HYPOGAMMAGLOBULINEMIA UNSPECIFIED - OTHER DEFICIENCY OF HUMORAL IMMUNITY
279.10 - 279.19	IMMUNODEFICIENCY WITH PREDOMINANT T-CELL DEFECT UNSPECIFIED - OTHER DEFICIENCY OF CELL-MEDIATED IMMUNITY
279.2	COMBINED IMMUNITY DEFICIENCY
279.3	UNSPECIFIED IMMUNITY DEFICIENCY
279.4	AUTOIMMUNE DISEASE NOT ELSEWHERE CLASSIFIED
279.50	GRAFT-VERSUS-HOST DISEASE, UNSPECIFIED
279.51	ACUTE GRAFT-VERSUS-HOST DISEASE
279.52	CHRONIC GRAFT-VERSUS-HOST DISEASE
279.53	ACUTE ON CHRONIC GRAFT-VERSUS-HOST DISEASE
279.8	OTHER SPECIFIED DISORDERS INVOLVING THE IMMUNE MECHANISM
279.9	UNSPECIFIED DISORDER OF IMMUNE MECHANISM
285.21 - 285.29	ANEMIA IN CHRONIC KIDNEY DISEASE - ANEMIA OF OTHER CHRONIC DISEASE
285.9	ANEMIA UNSPECIFIED
307.1	ANOREXIA NERVOSA
307.51	BULIMIA NERVOSA
356.0 - 356.9	HEREDITARY PERIPHERAL NEUROPATHY - UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY
403.11	HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
428.0 - 428.9	CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED
555.0 - 555.9	REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF UNSPECIFIED SITE
556.0 - 556.3	ULCERATIVE (CHRONIC) ENTEROCOLITIS - ULCERATIVE (CHRONIC) PROCTOSIGMOIDITIS
556.5 - 556.6	LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS - UNIVERSAL ULCERATIVE (CHRONIC) COLITIS
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
579.3	OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION
579.8	OTHER SPECIFIED INTESTINAL MALABSORPTION
580.0 - 588.9	ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION
592.0 - 592.9	CALCULUS OF KIDNEY - URINARY CALCULUS UNSPECIFIED
694.0 - 694.8	DERMATITIS HERPETIFORMIS - OTHER SPECIFIED BULLOUS DERMATOSES
695.10	ERYTHEMA MULTIFORME, UNSPECIFIED
695.11	ERYTHEMA MULTIFORME MINOR
695.12	ERYTHEMA MULTIFORME MAJOR
695.13	STEVENS-JOHNSON SYNDROME
695.14	STEVENS-JOHNSON SYNDROME-TOXIC EPIDERMAL NECROLYSIS OVERLAP SYNDROME
695.15	TOXIC EPIDERMAL NECROLYSIS
695.19	OTHER ERYTHEMA MULTIFORME
695.50	EXFOLIATION DUE TO ERYTHEMATOUS CONDITION INVOLVING LESS THAN 10 PERCENT OF BODY SURFACE
695.51	EXFOLIATION DUE TO ERYTHEMATOUS CONDITION INVOLVING 10-19 PERCENT OF BODY SURFACE
695.52	EXFOLIATION DUE TO ERYTHEMATOUS CONDITION INVOLVING 20-29 PERCENT OF BODY SURFACE
695.53	EXFOLIATION DUE TO ERYTHEMATOUS CONDITION INVOLVING 30-39 PERCENT OF BODY SURFACE
695.54	EXFOLIATION DUE TO ERYTHEMATOUS CONDITION INVOLVING 40-49 PERCENT OF BODY SURFACE
695.55	EXFOLIATION DUE TO ERYTHEMATOUS CONDITION INVOLVING 50-59 PERCENT OF BODY SURFACE
695.56	EXFOLIATION DUE TO ERYTHEMATOUS CONDITION INVOLVING 60-69 PERCENT OF BODY SURFACE
695.57	EXFOLIATION DUE TO ERYTHEMATOUS CONDITION INVOLVING 70-79 PERCENT OF BODY SURFACE
695.58	EXFOLIATION DUE TO ERYTHEMATOUS CONDITION INVOLVING 80-89 PERCENT OF BODY SURFACE
695.59	EXFOLIATION DUE TO ERYTHEMATOUS CONDITION INVOLVING 90 PERCENT OR MORE OF BODY SURFACE
707.00	PRESSURE ULCER, UNSPECIFIED SITE
707.01 - 707.09	PRESSURE ULCER, ELBOW - PRESSURE ULCER, OTHER SITE
707.11 - 707.19	ULCER OF THIGH - ULCER OF OTHER PART OF LOWER LIMB
707.20	PRESSURE ULCER, UNSPECIFIED STAGE
707.21	PRESSURE ULCER, STAGE I
707.22	PRESSURE ULCER, STAGE II
707.23	PRESSURE ULCER, STAGE III
707.24	PRESSURE ULCER, STAGE IV
707.25	PRESSURE ULCER, UNSTAGEABLE
707.8	CHRONIC ULCER OF OTHER SPECIFIED SITES
710.0	SYSTEMIC LUPUS ERYTHEMATOSUS
714.0	RHEUMATOID ARTHRITIS
733.10 - 733.19	PATHOLOGICAL FRACTURE UNSPECIFIED SITE - PATHOLOGICAL FRACTURE OF OTHER SPECIFIED SITE
782.3	EDEMA
783.0	ANOREXIA
783.21 - 783.22	LOSS OF WEIGHT - UNDERWEIGHT
783.7	ADULT FAILURE TO THRIVE
785.6	ENLARGEMENT OF LYMPH NODES
942.30 - 942.59	FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF TRUNK - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK WITH LOSS OF A BODY PART
943.30 - 943.59	FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF UPPER LIMB - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND WITH LOSS OF UPPER LIMB
945.30 - 945.59	FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF UNSPECIFIED SITE OF LOWER LIMB - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SITES OF LOWER LIMB(S) WITH LOSS OF A BODY PART
946.3 - 946.5	FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SPECIFIED SITES - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SPECIFIED SITES WITH LOSS OF A BODY PART
947.0 - 947.9	BURN OF MOUTH AND PHARYNX - BURN OF INTERNAL ORGAN UNSPECIFIED SITE
948.10 - 948.99	BURN (ANY DEGREE) INVOLVING 10-19 PERCENT OF BODY SURFACE WITH THIRD DEGREE BURN OF LESS THAN 10 PERCENT OR UNSPECIFIED AMOUNT - BURN (ANY DEGREE) INVOLVING 90 PERCENT OR MORE OF BODY SURFACE WITH THIRD DEGREE BURN OF 90% OR MORE OF BODY SURFACE
V15.87	PERSONAL HISTORY OF EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO)

Diagnoses that Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity ^{back to top}

N/A

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation ^{back to top}

Diagnoses that DO NOT Support Medical Necessity ^{back to top}

N/A

General Information

Documentation Requirements ^{back to top}

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the Intermediary upon request.

The physician should state the clinical indication with the order for the test.

Appendices ^{back to top}

N/A

Utilization Guidelines ^{back to top}

Routine serum protein laboratory tests (84155 or 84160), those performed at a frequency of one per month for hemodialysis, intermittent peritoneal dialysis and continuous cycling peritoneal dialysis beneficiaries are included in the renal facility’s composite rate and may not be billed separately to the Medicare program.

Routine tests performed for continuous ambulatory peritoneal dialysis beneficiaries in a certified setting are also included in the facility’s composite rate. Services performed at a greater frequency than specified are separately billable if medically necessary.

A diagnosis of chronic kidney disease (ICD-9-CM code 585.1-585.9) alone is not sufficient medical evidence to warrant coverage of additional tests.

This policy applies to scenarios where an individual serum protein test is ordered.

Sources of Information and Basis for Decision ^{back to top}

Fauci AS, Braunwald E, Isselbacher KJ, et al. Harrison’s Principles of Internal Medicine.14th ed. 1998.

Wallach JB. Interpretation of Diagnostic Tests. 7th ed. 2000.

Advisory Committee Meeting Notes ^{back to top}

This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the Intermediary, this policy was developed in cooperation with advisory groups, which include representatives from the affected provider community. Advisory Committee Meeting Date: N/A.

Start Date of Comment Period ^{back to top}

03/09/2001

End Date of Comment Period ^{back to top}

04/24/2001

Start Date of Notice Period ^{back to top}

06/15/2001

Revision History Number ^{back to top}

Revision #15, 12/04/2008
Revision #14, 10/01/2008
Revision #13, 10/01/2007
Revision #12, 01/18/2007
Revision #11, 10/01/2006
Revision #10, 11/16/2005
Revision #9, 10/01/2005
Revision #8, 08/18/2005
Revision #7, 01/01/2005
Revision #6, 11/22/2004
Revision #5, 10/01/2004
Revision #4, 11/28/2003
Revision #3, 10/01/2003
Revision #2, 09/17/2002
Revision #1, 04/01/2002

Revision History Explanation ^{back to top}

Revision #15, 12/04/2008
In the previous revision (#14, 10/01/2008) the ICD-9 code 707.21 was omitted from the revision history. This revision becomes effective on 12/04/2008.

Revision #14, 10/01/2008
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2007 to 2008. Under ICD-9 Codes That Support Medical Necessity revised ICD-9 codes 203.00 and 203.01, and added ICD-9 codes 203.02, 203.12, 203.82, 204.02, 204.12, 204.22, 204.82, 204.92, 208.02, 208.12, 208.22, 208.82, 208.92, 238.77, 275.5, 279.50, 279.51, 279.52, 279.53,571.42, 695.10, 695.11, 695.12, 695.13, 695.14, 695.15, 695.19, 695.50, 695.51, 695.52, 695.53, 695.54, 695.55, 695.56, 695.57, 695.58, 695.59, 707.20, 707.22, 707.23, 707.24 and 707.25. This revision becomes effective 10/01/2008.

Revision #13, 10/01/2007
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2006 to 2007. Under CMS National Coverage Policy revised the publication number for the cited references “100-2”, and “100-8” to now read “100-02” and “100-08”. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 200.30-200.38, 200.40-200.48, 200.50-200.58, 200.60-200.68, 200.70-200.78 and 202.70-202.78. This revision becomes effective 10/01/2007.

Revision #12, 01/18/2007
Under CMS National Coverage Policy corrected a typographical error-changed 2005 to now read 2004 for the reference cited: CMS Manual System, Pub 100-8, Medicare Program Integrity Manual, Transmittal 63. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 200.00-200.88, 202.00-202.08, 202.80-202.88, 202.90-202.98, 203.10-203.81, 204.00-204.91, 208.00-208.91, 238.6, 275.42, 275.49, 279.00-279.9, 285.21-285.29, 285.9, 356.0-356.9, 592.0-592.9, 733.10-733.19, and 785.6. This revision becomes effective 01/18/2007.

Revision #11, 10/01/2006
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2005 to 2006. Under CMS National Coverage Policy added section 70.3 to CMS Manual System, Pub 100-2, Medicare Benefit Policy Manual, Chapter 11. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 277.30-277.39. The verbiage was changed for ICD-9 code 403.11. Under Utilization Guidelines in paragraph #3 changed “ESRD” to “chronic kidney disease”. Under Sources of Information and Basis for Decision the references were placed in the AMA citation format. Under Advisory Committee Meeting Notes the verbiage was changed. This policy was reviewed for annual validation. This revision becomes effective 10/01/2006.

Revision #10, 11/16/2005
This revision is to correct a typographical error in the revision #9 verbiage. The ICD-9 code 276.5 was expanded to 276.50, 276.51, and 276.52 not 279.50 and 279.51 as previously stated. This change becomes effective 11/16/2005.

Revision #9, 10/01/2005
Under AMA/CPT & ADA/CDT Copyright Statement section of the policy the copyright date was changed from 2004-2005. The revenue codes 0300 and 0301 were changed to 030x. Under ICD-9 Codes That Support Medical Necessity section of the policy 276.5 has been expanded to 279.50, 279.51, and 276.52. These changes become effective on 10/01/2005.

Revision #8, 08/19/2005
Under CMS National Coverage Policy section the change request 2592 was deleted. The following citations have been added:Title XVIII of the Social Security Act, section 1862 (a)(1)(A)CMS Manual System, Pub. 100-02, Medicare Benefit Policy, Transmittal 35, dated June 3, 2005, Change Request 3802CMS Manual System, Pub. 100-08, Medicare Program Integrity, Transmittal 63, dated January 23, 2005, Change Request 3010.Under Type of Bill Code section Federally Qualified Health Centers (FQHC) has been added. These changes become effective 08/19/2005.

Revision #7, 01/01/2005
Correction to revision #6, the verbiage change for CPT code 84165 is effective 01/01/2005 not 11/22/2004. This revision becomes effective 01/01/2005.

Revision #6, 11/22/2004
Under AMA CPT Copyright statement section of this policy, deleted references to CDT-4 copyright language, as this policy does not contain CDT-4 codes or descriptions. Under the CPT/HCPCS codes section of this policy a verbiage change was made to code 84165, which now reads protein, electrophoretic fractionation and quantitation, serum. This revision becomes effective 11/22/2004.

Revision #5, 10/01/2004
Under AMA CPT Copyright Statement added American Dental Association copyright statement. Under CMS National Coverage Policy deleted citations-CMS Manual System, Pub 100-2, Medicare Benefit Policy, Chapter 11, Section 70 and CMS Manual System, Pub 100-4, Medicare Claims Processing, Chapter 3, Section 40.4. Under ICD-9 Codes That Support Medical Necessity verbiage changed to comply with ICD-9 annual update for ICD-9 307.51. ICD-9 codes 001-009 were extended to 001.0-009.0. ICD- 9 codes 010-016 were extended to 010.00-016.06. Added ICD-9 code 403.11. ICD-9 code 707.0 extended to a 5th digit 707.00. Added ICD-9 codes 707.01-707.09. These changes become effective 10/01/2004.

Revision #4, 11/28/2003
Under CMS National Coverage Policy section of this policy the manual citations have been changed to reflect the Internet-Only Manual (IOM). Under CPT/HCPCS Codes section there were verbiage changes to 84155 and 84160. These changes become effective 11/28/03.

Revision #3, 10/01/2003
Under AMA CPT Copyright Statement section of this policy the copyright date has been changed from 2002 to 2003. ICD-9-CM code V15.87 has been added to the list of ICD-9-CM Codes That Support Medical Necessity. This change will become effective 10/01/2003.

Revision #2 09/17/2002
Under Type of Bill Code section, Critical Access Hospital (85x) has been added. This change becomes effective 10/01/02.

Revision #1 04/01/2002
Verbiage under Indications and Limitations of Coverage and/or Medical Necessity section and under Coding Guidelines has been changed to state that this policy applies to scenarios where an individual serum protein test is ordered. ** This policy does not apply to serum protein determinations performed as part of an organ/disease panel.

11/07/2004 - The description for CPT/HCPCS code 84165 was changed in group 1

This LCD was converted from an LMRP on 7/22/2005

Reason for Change ^{back to top}

Maintenance (annual review with new changes, formatting, etc.)
Narrative Change

Last Reviewed On Date ^{back to top}

11/19/2008

Medicare Coverage Database

LCD for Serum Protein (L10354)