SUPERCEDED LCD: Centers for Medicare & Medicaid Services

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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}

L1228

LCD Title ^{back to top}
Serum Potassium

Contractor's Determination Number ^{back to top}
98A-0017-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. Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations. 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 09/21/1998

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}


Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Potassium is the major cation in intracellular fluid and is of primary importance in its maintenance. In conjunction with sodium and chloride, it aids in regulation of osmotic pressure and acid-base balance. Potassium is essential for normal excitability of muscle tissue and plays a role in the conduction of nerve impulses. The serum potassium level is a blood test which reveals the body's (serum) potassium level and is helpful in diagnosing potassium imbalances as related to medical conditions (such as complications of diabetes mellitus, complications of acute renal failure, hypokalemia and/or hyperkalemia). This test is also utilized to monitor the efficacy of medical interventions or treatments specific to the condition under treatment. This Intermediary will provide reimbursement for the serum potassium laboratory study which is determined to be medically necessary based on documented signs or symptoms, illnesses or injuries.

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.

030X	Laboratory-general classification

CPT/HCPCS Codes ^{back to top}

84132 POTASSIUM; SERUM, PLASMA OR WHOLE BLOOD

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

079.82	SARS-ASSOCIATED CORONAVIRUS INFECTION
079.83	PARVOVIRUSB19
249.00	SECONDARY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.01	SECONDARY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, UNCONTROLLED
249.10	SECONDARY DIABETES MELLITUS WITH KETOACIDOSIS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.11	SECONDARY DIABETES MELLITUS WITH KETOACIDOSIS, UNCONTROLLED
249.20	SECONDARY DIABETES MELLITUS WITH HYPEROSMOLARITY, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.21	SECONDARY DIABETES MELLITUS WITH HYPEROSMOLARITY, UNCONTROLLED
249.30	SECONDARY DIABETES MELLITUS WITH OTHER COMA, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.31	SECONDARY DIABETES MELLITUS WITH OTHER COMA, UNCONTROLLED
249.40	SECONDARY DIABETES MELLITUS WITH RENAL MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.41	SECONDARY DIABETES MELLITUS WITH RENAL MANIFESTATIONS, UNCONTROLLED
249.50	SECONDARY DIABETES MELLITUS WITH OPHTHALMIC MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.51	SECONDARY DIABETES MELLITUS WITH OPHTHALMIC MANIFESTATIONS, UNCONTROLLED
249.60	SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.61	SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS, UNCONTROLLED
249.70	SECONDARY DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.71	SECONDARY DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS, UNCONTROLLED
249.80	SECONDARY DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.81	SECONDARY DIABETES MELLITUS WITH OTHER SPECIFIED MANIFESTATIONS, UNCONTROLLED
249.90	SECONDARY DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION, NOT STATED AS UNCONTROLLED, OR UNSPECIFIED
249.91	SECONDARY DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION, UNCONTROLLED
250.00 - 250.93	DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED
251.0 - 251.9	HYPOGLYCEMIC COMA - UNSPECIFIED DISORDER OF PANCREATIC INTERNAL SECRETION
252.00 - 252.9	HYPERPARATHYROIDISM, UNSPECIFIED - UNSPECIFIED DISORDER OF PARATHYROID GLAND
253.0 - 253.9	ACROMEGALY AND GIGANTISM - UNSPECIFIED DISORDER OF THE PITUITARY GLAND AND ITS HYPOTHALAMIC CONTROL
254.0 - 254.9	PERSISTENT HYPERPLASIA OF THYMUS - UNSPECIFIED DISEASE OF THYMUS GLAND
255.0	CUSHING'S SYNDROME
255.10	HYPERALDOSTERONISM, UNSPECIFIED
255.11	GLUCOCORTICOID-REMEDIABLE ALDOSTERONISM
255.12	CONN'S SYNDROME
255.13	BARTTER'S SYNDROME
255.14	OTHER SECONDARY ALDOSTERONISM
255.2 - 255.3	ADRENOGENITAL DISORDERS - OTHER CORTICOADRENAL OVERACTIVITY
255.41	GLUCOCORTICOID DEFICIENCY
255.42	MINERALOCORTICOID DEFICIENCY
255.5 - 255.9	OTHER ADRENAL HYPOFUNCTION - UNSPECIFIED DISORDER OF ADRENAL GLANDS
256.0 - 256.8	HYPERESTROGENISM - OTHER OVARIAN DYSFUNCTION
257.0 - 257.8	TESTICULAR HYPERFUNCTION - OTHER TESTICULAR DYSFUNCTION
258.01	MULTIPLE ENDOCRINE NEOPLASIA [MEN] TYPE I
258.02	MULTIPLE ENDOCRINE NEOPLASIA [MEN] TYPE IIA
258.03	MULTIPLE ENDOCRINE NEOPLASIA [MEN] TYPE IIB
258.1	OTHER COMBINATIONS OF ENDOCRINE DYSFUNCTION
258.8	OTHER SPECIFIED POLYGLANDULAR DYSFUNCTION
259.0	DELAY IN SEXUAL DEVELOPMENT AND PUBERTY NOT ELSEWHERE CLASSIFIED
259.1	PRECOCIOUS SEXUAL DEVELOPMENT AND PUBERTY NOT ELSEWHERE CLASSIFIED
259.2	CARCINOID SYNDROME
259.3	ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED
259.4	DWARFISM NOT ELSEWHERE CLASSIFIED
259.50	ANDROGEN INSENSITIVITY, UNSPECIFIED
259.51	ANDROGEN INSENSITIVITY SYNDROME
259.52	PARTIAL ANDROGEN INSENSITIVITY
259.8	OTHER SPECIFIED ENDOCRINE DISORDERS
259.9	UNSPECIFIED ENDOCRINE DISORDER
263.9	UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
276.2 - 276.9	ACIDOSIS - ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED
277.30 - 277.39	AMYLOIDOSIS, UNSPECIFIED - OTHER AMYLOIDOSIS
277.89	OTHER SPECIFIED DISORDERS OF METABOLISM
359.21	MYOTONIC MUSCULAR DYSTROPHY
359.22	MYOTONIA CONGENITAL
359.23	MYOTONIC CHONDRODYSTROPHY
359.24	DRUG INDUCED MYOTONIA
359.29	OTHER SPECIFIED MYOTONIC DISORDER
359.3	PERIODIC PARALYSIS
401.0 - 401.9	MALIGNANT ESSENTIAL HYPERTENSION - UNSPECIFIED ESSENTIAL HYPERTENSION
402.00 - 402.91	MALIGNANT HYPERTENSIVE HEART DISEASE WITHOUT HEART FAILURE - UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE
403.00 - 403.91	HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
404.00 - 404.93	HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED - HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
405.01 - 405.99	MALIGNANT RENOVASCULAR HYPERTENSION - OTHER UNSPECIFIED SECONDARY HYPERTENSION
410.00 - 410.92	ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE
415.0	ACUTE COR PULMONALE
426.0 - 426.9	ATRIOVENTRICULAR BLOCK COMPLETE - CONDUCTION DISORDER UNSPECIFIED
427.0 - 427.9	PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - CARDIAC DYSRHYTHMIA UNSPECIFIED
428.0 - 428.9	CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED
429.0 - 429.6	MYOCARDITIS UNSPECIFIED - RUPTURE OF PAPILLARY MUSCLE
429.71 - 429.79	CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT ELSEWHERE CLASSIFIED ACQUIRED CARDIAC SEPTAL DEFECT - CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT ELSEWHERE CLASSIFIED OTHER
429.81 - 429.89	OTHER DISORDERS OF PAPILLARY MUSCLE - OTHER ILL-DEFINED HEART DISEASES
429.9	HEART DISEASE UNSPECIFIED
480.3	PNEUMONIA DUE TO SARS-ASSOCIATED CORONAVIRUS
560.0 - 560.9	INTUSSUSCEPTION - UNSPECIFIED INTESTINAL OBSTRUCTION
580.0 - 580.9	ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
581.0 - 581.9	NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
582.0 - 582.9	CHRONIC GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
583.0 - 583.9	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
584.5 - 584.9	ACUTE RENAL FAILURE WITH LESION OF TUBULAR NECROSIS - ACUTE RENAL FAILURE UNSPECIFIED
585.1 - 585.9	CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED
586	RENAL FAILURE UNSPECIFIED
587	RENAL SCLEROSIS UNSPECIFIED
588.0 - 588.9	RENAL OSTEODYSTROPHY - UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION
589.0 - 589.9	UNILATERAL SMALL KIDNEY - SMALL KIDNEY UNSPECIFIED
728.88	RHABDOMYOLYSIS
729.71 - 729.79	NONTRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY - NONTRAUMATIC COMPARTMENT SYNDROME OF OTHER SITES
729.82	CRAMP OF LIMB
781.0	ABNORMAL INVOLUNTARY MOVEMENTS
787.01	NAUSEA WITH VOMITING
787.02	NAUSEA ALONE
787.03	VOMITING ALONE
787.91	DIARRHEA
788.41 - 788.43	URINARY FREQUENCY - NOCTURIA
788.5	OLIGURIA AND ANURIA
788.64	URINARY HESITANCY
788.65	STRAINING ON URINATION
788.99	OTHER SYMPTOMS INVOLVING URINARY SYSTEM
926.11 - 926.8	CRUSHING INJURY OF BACK - CRUSHING INJURY OF MULTIPLE SITES OF TRUNK
927.00 - 927.8	CRUSHING INJURY OF SHOULDER REGION - CRUSHING INJURY OF MULTIPLE SITES OF UPPER LIMB
928.00 - 928.8	CRUSHING INJURY OF THIGH - CRUSHING INJURY OF MULTIPLE SITES OF LOWER LIMB
929.0	CRUSHING INJURY OF MULTIPLE SITES NOT ELSEWHERE CLASSIFIED
948.00 - 948.99	BURN (ANY DEGREE) INVOLVING LESS THAN 10 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
974.4	POISONING BY OTHER DIURETICS
V58.11	ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY
V58.12	ENCOUNTER FOR IMMUNOTHERAPY FOR NEOPLASTIC CONDITION
V58.64	LONG-TERM (CURRENT) USE OF NONSTEROIDAL ANTI-INFLAMMATORIES
V58.69	LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
V67.51	FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED

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.

Appendices ^{back to top}

N/A

Utilization Guidelines ^{back to top}

N/A

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

Mosby’s Diagnostic and Laboratory Test Reference. 2nd Edition. 1995.

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}

06/02/1998

End Date of Comment Period ^{back to top}

07/17/1998

Start Date of Notice Period ^{back to top}

08/21/1998

Revision History Number ^{back to top}

Revision #14, 12/04/2008
Revision #13, 10/01/2008
Revision #12, 10/01/2007
Revision #11, 10/01/2006
Revision #10, 11/09/2005
Revision #9, 10/01/2005
Revision #8, 05/12/2005
Revision #7, 11/22/2004
Revision #6, 10/01/2004
Revision #5, 10/01/2003
Revision #4, 09/11/2002
Revision #3, 04/01/2002
Revision #2, 04/15/2000
Revision #1, 11/15/1998

Revision History Explanation ^{back to top}

Revision #14, 12/04/2008
In the previous revision (#13, 10/01/2008) the ICD-9 code 249.70 was erroneously typed as 259.70. This revision is to correct the typographical error. This revision becomes effective on 12/04/2008.

Revision #13, 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 added ICD-9 codes 249.00, 249.01, 249.10, 249.11, 249.20, 249.21, 249.30, 249.31, 249.40, 249.41, 249.50, 249.51, 249.60, 249.61, 259.70, 249.71, 249.80, 249.81, 249.90, 249.91 and 788.99. ICD-9 code 259.5 was expanded to a 5th digit to now read 259.50, 259.51 and 259.52. This revision becomes effective 10/01/2008.

Revision #12, 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 referenced manual citation from “100-8” to now read “100-08”. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 079.83, 359.21, 359.22, 359.23, 359.24, 359.29 and 359.3. ICD-9 code 255.4 was expanded to a 5th digit to now read 255.41 and 255.42. ICD-9 code 258.0 was expanded to a 5th digit to now read 258.01, 258.02, and 258.03. This policy was reviewed for annual validation. This revision becomes effective 10/01/2007.

Revision #11, 10/01/2006
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2005 to 2006. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 277.30-277.39, 729.71-729.79, 788.64 and 788.65. Revised the verbiage for 255.10, 403.00-403.91, and 404.00-404.93. Under Documentation Requirements deleted statements #1 and #2. This policy was reviewed for annual validation. This policy becomes effective 10/01/2006.

Revision #10, 11/09/2005
Under CMS National Coverage Policy revised the verbiage for Title XVIII of the Social Security Act, section 1862 (a)(7). Under Bill Type Codes added 72x End Stage Renal Disease (ESRD) bill type. This revision becomes effective 11/09/2005.

Revision #9, 10/01/2005
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2004 to 2005. Under Bill Type Codes 73x for Federally Qualified Health Centers was added. Under ICD-9 Codes That Support Medical Necessity section of the policy the word renal has been changed to kidney in ICD-9 codes 403.00-403.91 and 404.00-404.93. ICD-9 code 585 has expanded to 585.1-585.9 and V58.1 has been expanded to V58.11 and V58.12. Under Documentation Requirements #3 was changed to read, “Documentation requirements must be kept on file in the patient’s medical record and be available to the Intermediary upon request.” Under Sources of Information and Basis for Decision section the statement Other Fiscal Intermediaries Local Coverage Determinations was deleted. These changes become effective on 10/1/2005.

Revision #8, 05/12/2005
Converted the Local Medical Review Policy (LMRP) to a Local Coverage Determination (LCD). This revision becomes effective 04/29/2005.

Under CMS National Coverage Policy section of the policy verbiage changed for Title XVIII of the Social Security Act, section 1862 (a)(1)(A). Deleted Change Request 2592. Added Change Request 3010. Under Indications and Limitations of Coverage and/or Medical Necessity added paragraphs #2 and #3. Under Revenue Codes changed 0300 to 030X. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 256.0-256.8, 257.0-257.8, 258.0-258.8, 277.89, 415.0, 729.82, 781.0, 787.02, 788.41-788.43, 788.5, 926.11-926.8, 927.00-927.8, 928.00-928.8, 929.0, 948.00-948.99, and V58.69. Under Documentation Requirements added statement #1. Under Sources of Information and Basis For Decision added Mosby’s Diagnostic and Laboratory Test Reference, 2nd Edition; 1995. Under Advisory Committee Notes verbiage changed. This revision becomes effective 05/12/2005.

Revision #7, 11/22/2004
Under AMA CPT Copyright Statement section of this policy, deleted the reference to CDT-4 copyright language, as this policy does not contain CDT-4 codes or descriptions. Under ICD-9 Codes That Support Medical Necessity section of the policy deleted the verbiage related to Appeal rights, as this information will appear on the Palmetto GBA web site under Appeals information. Under Sources of Information and Basis for Decision changed Local Medical Review Policy to Local Coverage Determination. Under Advisory Committee Notes added verbiage related to “review by affected providers”. These changes become effective 11/22/2004.

Revision #6, 10/01/2004
Under AMA CPT Copyright Statement section of this policy the copyright date has been changed from 2003 to 2004. Added American Dental Association copyright statement. Under ICD-9 Codes That Support Medical Necessity section of the policy extended ICD-9 code 252.0 to 5th digit 252.00. These changes become effective 10/01/2004.

Revision #5 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 codes 079.82, 255.10, 255.11, 255.12, 255.13, 255.14, 480.3, 728.88, V58.64 have been added to the list of ICD-9-CM Codes That Support Medical Necessity section of this policy. ICD-9-CM code 255.1 and V58.69 have been deleted. These changes will become effective 10/01/2003.

Revision #4 09/11/2002
Under Type of Bill Code section Critical Access Hospital (85x) has been added to the policy. This change becomes effective 10/01/02.

Revision #3 04/01/2002
Verbiage under Coding Guidelines changed to state that this policy applies to scenarios where an individual serum potassium test is ordered. ** This policy does not apply to serum potassium determinations performed as part of an organ/disease panel.

Revision #2 04/15/2000

Revision #1 11/15/1998

This LCD was converted from an LMRP on 4/28/2005

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 Potassium (L1228)