SUPERCEDED LCD: Centers for Medicare & Medicaid Services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}

L1305

LCD Title ^{back to top}
Hepatic Function Panel

Contractor's Determination Number ^{back to top}
01A-0016-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

Secondary Geographic Jurisdiction ^{back to top}


Oversight Region ^{back to top}
Region IV

Original Determination Effective Date ^{back to top}
For services performed on or after 04/01/2002

Original Determination Ending Date ^{back to top}


Revision Effective Date ^{back to top}
For services performed on or after 10/09/2008

Revision Ending Date ^{back to top}
09/02/2009

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
This chemistry panel is an organ specific panel used in the diagnosis and management of various illnesses and injuries related to the liver. The panel must consist of the stated tests identified within CPT code 80076 and all tests must be performed. This panel may be used to aid in the diagnosis and classification of liver disease (e.g. parenchymal, hepatobiliary, vascular). These conditions may include but are not limited to: a. Congenital b. Inflammatory c. Toxin induced d. Neoplastic, or e. Iatrogenic LIMITATIONS: Screening tests are defined as those tests done in the course of an annual physical examination or as part of a routine physical checkup, without signs, symptoms, or the presence of an illness. The panel covered by this Local Coverage Determination when done as a screening test would not be a covered Medicare benefit.

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
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}

Panel must include:

82040 Albumin

82247 Bilirubin, total

82248 Bilirubin, direct

84075 Phosphatase, alkaline

84155 Protein, total

84460 Transferase, alanine amino (ALT) (SGPT)

84450 Transferase, aspartate amino (AST) (SGOT)

80076 HEPATIC FUNCTION PANEL

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

006.3	AMEBIC LIVER ABSCESS
010.00 - 018.96	PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - UNSPECIFIED MILIARY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
042	HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
070.0 - 070.9	VIRAL HEPATITIS A WITH HEPATIC COMA - UNSPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA
100.0	LEPTOSPIROSIS ICTEROHEMORRHAGICA
114.1	PRIMARY EXTRAPULMONARY COCCIDIOIDOMYCOSIS
114.3	OTHER FORMS OF PROGRESSIVE COCCIDIOIDOMYCOSIS
115.05	HISTOPLASMA CAPSULATUM PNEUMONIA
115.09	INFECTION BY HISTOPLASMA CAPSULATUM WITH OTHER MANIFESTATION
115.15	HISTOPLASMA DUBOISII PNEUMONIA
115.19	INFECTION BY HISTOPLASMA DUBOISII WITH OTHER MANIFESTATION
115.95	HISTOPLASMOSIS PNEUMONIA UNSPECIFIED
115.99	HISTOPLASMOSIS UNSPECIFIED WITH OTHER MANIFESTATION
116.0 - 116.1	BLASTOMYCOSIS - PARACOCCIDIOIDOMYCOSIS
117.7	ZYGOMYCOSIS (PHYCOMYCOSIS OR MUCORMYCOSIS)
120.1	SCHISTOSOMIASIS DUE TO SCHISTOSOMA MANSONI
121.0	OPISTHORCHIASIS
121.1	CLONORCHIASIS
121.3	FASCIOLIASIS
121.4	FASCIOLOPSIASIS
121.9	TREMATODE INFECTION UNSPECIFIED
122.0	ECHINOCOCCUS GRANULOSUS INFECTION OF LIVER
130.5	HEPATITIS DUE TO TOXOPLASMOSIS
135	SARCOIDOSIS
151.0 - 151.9	MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE
152.0 - 152.9	MALIGNANT NEOPLASM OF DUODENUM - MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE
153.0 - 153.9	MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE
154.0 - 154.8	MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION - MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS
155.0 - 155.2	MALIGNANT NEOPLASM OF LIVER PRIMARY - MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY
156.0 - 156.9	MALIGNANT NEOPLASM OF GALLBLADDER - MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE
157.0 - 157.3	MALIGNANT NEOPLASM OF HEAD OF PANCREAS - MALIGNANT NEOPLASM OF PANCREATIC DUCT
162.0 - 162.9	MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED
172.0 - 172.9	MALIGNANT MELANOMA OF SKIN OF LIP - MELANOMA OF SKIN SITE UNSPECIFIED
174.0 - 174.9	MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE
175.0 - 175.9	MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST - MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST
197.0 - 197.8	SECONDARY MALIGNANT NEOPLASM OF LUNG - SECONDARY MALIGNANT NEOPLASM OF OTHER DIGESTIVE ORGANS AND SPLEEN
198.0 - 198.89	SECONDARY MALIGNANT NEOPLASM OF KIDNEY - SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES
199.0 - 199.1	DISSEMINATED MALIGNANT NEOPLASM - OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE
199.2	MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN
275.0	DISORDERS OF IRON METABOLISM
275.1	DISORDERS OF COPPER METABOLISM
277.30 - 277.39	AMYLOIDOSIS, UNSPECIFIED - OTHER AMYLOIDOSIS
277.4	DISORDERS OF BILIRUBIN EXCRETION
277.6	OTHER DEFICIENCIES OF CIRCULATING ENZYMES
428.0 - 428.9	CONGESTIVE HEART FAILURE UNSPECIFIED - HEART FAILURE UNSPECIFIED
452	PORTAL VEIN THROMBOSIS
555.9	REGIONAL ENTERITIS OF UNSPECIFIED SITE
570	ACUTE AND SUBACUTE NECROSIS OF LIVER
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
571.8	OTHER CHRONIC NONALCOHOLIC LIVER DISEASE
571.9	UNSPECIFIED CHRONIC LIVER DISEASE WITHOUT ALCOHOL
572.0 - 572.8	ABSCESS OF LIVER - OTHER SEQUELAE OF CHRONIC LIVER DISEASE
573.0 - 573.9	CHRONIC PASSIVE CONGESTION OF LIVER - UNSPECIFIED DISORDER OF LIVER
574.00 - 574.91	CALCULUS OF GALLBLADDER WITH ACUTE CHOLECYSTITIS WITHOUT OBSTRUCTION - CALCULUS OF GALLBLADDER AND BILE DUCT WITHOUT CHOLECYSTITIS WITH OBSTRUCTION
575.0 - 575.9	ACUTE CHOLECYSTITIS - UNSPECIFIED DISORDER OF GALLBLADDER
576.0 - 576.9	POSTCHOLECYSTECTOMY SYNDROME - UNSPECIFIED DISORDER OF BILIARY TRACT
577.0 - 577.1	ACUTE PANCREATITIS - CHRONIC PANCREATITIS
646.70 - 646.73	LIVER DISORDERS IN PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE - ANTEPARTUM LIVER DISORDERS
647.60 - 647.64	OTHER VIRAL DISEASES OF MOTHER COMPLICATING PREGNANCY CHILDBIRTH OR THE PUERPERIUM UNSPECIFIED AS TO EPISODE OF CARE - OTHER POSTPARTUM VIRAL DISEASES
698.9	UNSPECIFIED PRURITIC DISORDER
710.0	SYSTEMIC LUPUS ERYTHEMATOSUS
714.0	RHEUMATOID ARTHRITIS
774.4 - 774.6	PERINATAL JAUNDICE DUE TO HEPATOCELLULAR DAMAGE - UNSPECIFIED FETAL AND NEONATAL JAUNDICE
780.32	COMPLEX FEBRILE CONVULSIONS
780.60	FEVER, UNSPECIFIED
780.61	FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE
780.79	OTHER MALAISE AND FATIGUE
780.97	ALTERED MENTAL STATUS
782.4	JAUNDICE UNSPECIFIED NOT OF NEWBORN
789.00 - 789.09	ABDOMINAL PAIN UNSPECIFIED SITE - ABDOMINAL PAIN OTHER SPECIFIED SITE
789.1	HEPATOMEGALY
789.51	MALIGNANT ASCITES
789.59	OTHER ASCITES
790.4	NONSPECIFIC ELEVATION OF LEVELS OF TRANSAMINASE OR LACTIC ACID DEHYDROGENASE (LDH)
790.5	OTHER NONSPECIFIC ABNORMAL SERUM ENZYME LEVELS
794.8	NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF LIVER
965.1	POISONING BY SALICYLATES
965.4	POISONING BY AROMATIC ANALGESICS NOT ELSEWHERE CLASSIFIED
967.0 - 967.1	POISONING BY BARBITURATES - POISONING BY CHLORAL HYDRATE GROUP
969.1	POISONING BY PHENOTHIAZINE-BASED TRANQUILIZERS
969.4	POISONING BY BENZODIAZEPINE-BASED TRANQUILIZERS
V42.7	LIVER REPLACED BY TRANSPLANT
V58.61	LONG-TERM (CURRENT) USE OF ANTICOAGULANTS
V58.63	LONG-TERM (CURRENT) USE OF ANTIPLATELETS/ANTITHROMBOTICS
V58.64	LONG-TERM (CURRENT) USE OF NONSTEROIDAL ANTI-INFLAMMATORIES
V58.65	LONG-TERM (CURRENT) USE OF STEROIDS
V58.69	LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS

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}

All studies must have an interpretation on file and should be available for review. For studies done at the request of a referring physician, the order/requisition, with the medical indication, should be kept in the patient’s medical record.

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}

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

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: 11/05/2001.

Start Date of Comment Period ^{back to top}

10/05/2001

End Date of Comment Period ^{back to top}

11/19/2001

Start Date of Notice Period ^{back to top}

02/15/2002

Revision History Number ^{back to top}

Revision #10, 10/09/2008
Revision #9, 01/04/2008
Revision #8, 10/01/2007
Revision #7, 10/01/2006
Revision #6, 03/30/2005
Revision #5, 11/22/2004
Revision #4, 10/01/2004
Revision #3, 10/01/2003
Revision #2, 01/30/2003
Revision #1, 10/01/2002

Revision History Explanation ^{back to top}

Revision #10, 10/09/2008
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 199.2 and 571.42. ICD-9 code 780.6 extended to a 5th digit to 780.60 and 780.61. This revision is effective on 10/09/2008.

Revision #9, 01/04/2008
Under Revenue Codes changed the current revenue codes 300-309 to now read 030X. Under ICD-9 Codes That Support Medical Necessity added ICD-9 code V58.61. This policy was reviewed for annual validation. This revision becomes effective 01/04/2008.

Revision #8, 10/01/2007
Under the AMA/CPT & ADA/CDT Copyright Statement the copyright date has been updated from 2006 to 2007. Under CMS National Coverage Policy changed the publication number for the referenced manual from “100-8” to now read “100-08”. Under Indications and Limitations of Coverage and/or Medical Necessity changed the verbiage from “HCPCS” to read “CPT”. Under ICD-9 Codes That Support Medical Necessity, ICD-9 code 789.5 was extended to a 5th digit to now read 789.51 and 789.59. Under Advisory Committee Meeting Notes deleted the “s” from “includes”. This policy was reviewed for annual validation. This revision becomes effective 10/01/2007.

Revision #7, 10/01/2006
Under the AMA/CPT & ADA/CDT Copyright Statement the copyright date has been updated from 2005 to 2006. Under CMS National Coverage Policy the verbiage was changed. Under Bill Type Codes added 73X. Under ICD-9 Codes That Support Medical Necessity added ICD-9 codes 277.30-277.39, 780.32 and 780.97. Under Documentation Requirements the verbiage was changed for the last sentence. Under Sources of Information and Basis for Decision the reference was 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 #6, 03/30/2005
Converted LMRP to an LCD. This change becomes effective 03/16/2005.

Under CMS National Coverage Policy verbiage changed for Title XVIII of the Social Security Act, Section 1862(a)(1)(A). Added Change Request 3010. Under Indications and Limitations of Coverage and/or Medical Necessity added “…and all tests must be performed.” Under CPT/HCPCS Codes added, “Panel must include”. Under ICD-9 Codes That Support Medical Necessity added ICD-9 code 121.9. Under ICD-9 Codes That Do Not Support Medical Necessity deleted verbiage, added N/A. These changes become effective 03/30/2005.

Revision #5, 11/22/2004
Under Contractor Type section of the policy added “Fiscal”. Under the 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 Indications and Limitations of Coverage and/or Medical Necessity –Limitations section- changed Local Medical Review Policy to Local Coverage Determination. Under Coverage Topic changed Diagnostic Tests and X-rays to Lab Services. Under Non-covered ICD-9 Codes, deleted the verbiage related to Appeal rights, as this information will appear on the Palmetto GBA web site under Appeals information. These changes become effective 11/22/2004.

Revision #4, 10/01/2004
Under the AMA/CPT Copyright Statement of this policy the copyright date has been updated from 2003 to 2004. Per CMS the Dental copyright has been added. These changes become effective on 10/01/2004.

Revision #3, 10/01/2003
Under the AMA CPT Copyright Statement section of this policy the copyright date has been changed from 2002 to 2003. Under ICD-9 Codes That Support Medical Necessity section of this policy ICD-9 code 154.0-154.9 has been changed to 154.0-154.8, as there is no 154.9. Also codes V58.63, V58.64 and V58.65 have been added to the policy. These changes become effective on 10/01/2003.

Revision #2 01/30/2003
Addition of ICD-9 CM Code 275.0 was added as a covered diagnosis.

Revision #1 10/01/2002
Under Type of Bill Code section Critical Access Hospital (85x) has been added. This change becomes effective 10/01/02.

This LCD was converted from an LMRP on 3/15/2005

Reason for Change ^{back to top}

ICD9 Addition/Deletion
Maintenance (annual review with new changes, formatting, etc.)

Last Reviewed On Date ^{back to top}

10/03/2008

Medicare Coverage Database

LCD for Hepatic Function Panel (L1305)