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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}

L1308

LCD Title ^{back to top}
Ionized Calcium

Contractor's Determination Number ^{back to top}
97A-0003-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 10/17/2008

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

Indications and Limitations of Coverage and/or Medical Necessity ^{back to top}
Ionized calcium testing is used to evaluate non-bound calcium, a measure of the physiologically active calcium fraction. Total serum calcium is most often satisfactory for the evaluation of calcium metabolism. 1. Ionized calcium is infrequently needed, but it may be reasonable in hypo or hypercalcemia with borderline serum calcium and alterations of serum proteins. 2. Ionized calcium determination/testing may be reasonable in: kidney, liver or blood disorders, hypo or hyperthyroidism, rheumatoid arthritis, bone cancer, osteomalacia, osteoporosis, celiac disease, sprue, pancreatitis, malabsorption, ureteral calculus, hypo or hypercalcemia, coma, sarcoidosis, acute seizure, shock, respiratory failure, hyperparathyroidism, ectopic parathyroid hormone-producing neoplasms, excessive vitamin D, renal failure and/or kidney transplantation, in whom problems include secondary hyperparathyroidism; balance in dialysis patients, and ill premature infants with hypoproteinemia and acidosis. Calcium determination/testing is occasionally useful when hypercalcemia coexists with an abnormal protein state such as myeloma, disturbances of acid base balance, cirrhosis, hypoparathyroidism, vitamin D deficiency, pseudohypoparathyroidism, cardio-thoracic surgery and heart transplantation and may have some use in patients having cardiac arrest.

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}

82330 CALCIUM; IONIZED

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

010.00 - 012.86	PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - OTHER SPECIFIED RESPIRATORY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
015.00 - 015.96	TUBERCULOSIS OF VERTEBRAL COLUMN UNSPECIFIED EXAMINATION - TUBERCULOSIS OF UNSPECIFIED BONES AND JOINTS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
016.00 - 016.96	TUBERCULOSIS OF KIDNEY UNSPECIFIED EXAMINATION - UNSPECIFIED GENITOURINARY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
018.00 - 018.96	ACUTE MILIARY TUBERCULOSIS UNSPECIFIED EXAMINATION - UNSPECIFIED MILIARY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
038.0 - 038.9	STREPTOCOCCAL SEPTICEMIA - UNSPECIFIED SEPTICEMIA
135	SARCOIDOSIS
140.0 - 149.9	MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY
150.0 - 159.9	MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE ORGANS AND PERITONEUM
160.0 - 165.9	MALIGNANT NEOPLASM OF NASAL CAVITIES - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE RESPIRATORY SYSTEM
170.0 - 176.9	MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE - KAPOSI'S SARCOMA UNSPECIFIED SITE
179 - 189.9	MALIGNANT NEOPLASM OF UTERUS-PART UNS - MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED
190.0 - 199.1	MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE
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
201.00 - 201.98	HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.00 - 202.08	NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
202.10 - 202.18	MYCOSIS FUNGOIDES UNSPECIFIED SITE - MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES
202.20 - 202.28	SEZARY'S DISEASE UNSPECIFIED SITE - SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.30 - 202.38	MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE - MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.40 - 202.48	LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE - LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
202.50 - 202.58	LETTERER-SIWE DISEASE UNSPECIFIED SITE - LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
202.60 - 202.68	MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE - MALIGNANT MAST CELL TUMORS 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
205.00	ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.01	MYELOID LEUKEMIA ACUTE IN REMISSION
205.02	ACUTE MYELOID LEUKEMIA, IN RELAPSE
205.10	CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.11	MYELOID LEUKEMIA CHRONIC IN REMISSION
205.12	CHRONIC MYELOID LEUKEMIA, IN RELAPSE
205.20	SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.21	MYELOID LEUKEMIA SUBACUTE IN REMISSION
205.22	SUBACUTE MYELOID LEUKEMIA, IN RELAPSE
205.30	MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.31	MYELOID SARCOMA IN REMISSION
205.32	MYELOID SARCOMA, IN RELAPSE
205.80	OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.81	OTHER MYELOID LEUKEMIA IN REMISSION
205.82	OTHER MYELOID LEUKEMIA, IN RELAPSE
205.90	UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
205.91	UNSPECIFIED MYELOID LEUKEMIA IN REMISSION
205.92	UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE
206.00	ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.01	MONOCYTIC LEUKEMIA ACUTE IN REMISSION
206.02	ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE
206.10	CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.11	MONOCYTIC LEUKEMIA CHRONIC IN REMISSION
206.12	CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE
206.20	SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.21	MONOCYTIC LEUKEMIA SUBACUTE IN REMISSION
206.22	SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE
206.80	OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.81	OTHER MONOCYTIC LEUKEMIA IN REMISSION
206.82	OTHER MONOCYTIC LEUKEMIA, IN RELAPSE
206.90	UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
206.91	UNSPECIFIED MONOCYTIC LEUKEMIA IN REMISSION
206.92	UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE
207.00	ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.01	ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA IN REMISSION
207.02	ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE
207.10	CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.11	CHRONIC ERYTHREMIA IN REMISSION
207.12	CHRONIC ERYTHREMIA, IN RELAPSE
207.20	MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.21	MEGAKARYOCYTIC LEUKEMIA IN REMISSION
207.22	MEGAKARYOCYTIC LEUKEMIA, IN RELAPSE
207.80	OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
207.81	OTHER SPECIFIED LEUKEMIA IN REMISSION
207.82	OTHER SPECIFIED 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
208.21	LEUKEMIA OF UNSPECIFIED CELL TYPE SUBACUTE IN 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
242.90 - 242.91	THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE AND WITHOUT THYROTOXIC CRISIS OR STORM - THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM
252.00	HYPERPARATHYROIDISM, UNSPECIFIED
252.01 - 252.08	PRIMARY HYPERPARATHYROIDISM - OTHER HYPERPARATHYROIDISM
252.1	HYPOPARATHYROIDISM
252.8	OTHER SPECIFIED DISORDERS OF PARATHYROID GLAND
252.9	UNSPECIFIED DISORDER OF PARATHYROID GLAND
253.0	ACROMEGALY AND GIGANTISM
259.3	ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED
263.9	UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
268.0	RICKETS ACTIVE
268.1	RICKETS LATE EFFECT
268.2	OSTEOMALACIA UNSPECIFIED
268.9	UNSPECIFIED VITAMIN D DEFICIENCY
273.8	OTHER DISORDERS OF PLASMA PROTEIN METABOLISM
275.2	DISORDERS OF MAGNESIUM METABOLISM
275.3	DISORDERS OF PHOSPHORUS METABOLISM
275.40	UNSPECIFIED DISORDER OF CALCIUM METABOLISM
275.41	HYPOCALCEMIA
275.42	HYPERCALCEMIA
275.49	OTHER DISORDERS OF CALCIUM METABOLISM
275.5	HUNGRY BONE SYNDROME
275.8	OTHER SPECIFIED DISORDERS OF MINERAL METABOLISM
276.0	HYPEROSMOLALITY AND/OR HYPERNATREMIA
276.2	ACIDOSIS
276.3	ALKALOSIS
276.4	MIXED ACID-BASE BALANCE DISORDER
276.50	VOLUME DEPLETION, UNSPECIFIED
276.51	DEHYDRATION
276.52	HYPOVOLEMIA
276.6	FLUID OVERLOAD DISORDER
276.7	HYPERPOTASSEMIA
276.8	HYPOPOTASSEMIA
276.9	ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED
277.30 - 277.39	AMYLOIDOSIS, UNSPECIFIED - OTHER AMYLOIDOSIS
278.4	HYPERVITAMINOSIS D
401.1	BENIGN ESSENTIAL HYPERTENSION
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
403.90	HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED
403.91	HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
404.02	HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT 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
404.92	HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
427.5	CARDIAC ARREST
518.7	TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI)
518.81	ACUTE RESPIRATORY FAILURE
564.00	UNSPECIFIED CONSTIPATION
571.2	ALCOHOLIC CIRRHOSIS OF LIVER
571.40	CHRONIC HEPATITIS UNSPECIFIED
571.42	AUTOIMMUNE HEPATITIS
571.49	OTHER CHRONIC HEPATITIS
571.5	CIRRHOSIS OF LIVER WITHOUT ALCOHOL
571.6	BILIARY CIRRHOSIS
577.0	ACUTE PANCREATITIS
577.1	CHRONIC PANCREATITIS
579.0 - 579.4	CELIAC DISEASE - PANCREATIC STEATORRHEA
579.8 - 579.9	OTHER SPECIFIED INTESTINAL MALABSORPTION - UNSPECIFIED INTESTINAL MALABSORPTION
584.5	ACUTE RENAL FAILURE WITH LESION OF TUBULAR NECROSIS
584.6	ACUTE RENAL FAILURE WITH LESION OF RENAL CORTICAL NECROSIS
584.7	ACUTE RENAL FAILURE WITH LESION OF RENAL MEDULLARY (PAPILLARY) NECROSIS
584.8	ACUTE RENAL FAILURE WITH OTHER SPECIFIED PATHOLOGICAL LESION IN KIDNEY
584.9	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	RENAL OSTEODYSTROPHY
588.81 - 588.89	SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) - OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION
588.9	UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION
592.0 - 592.1	CALCULUS OF KIDNEY - CALCULUS OF URETER
594.2	CALCULUS IN URETHRA
594.8	OTHER LOWER URINARY TRACT CALCULUS
594.9	CALCULUS OF LOWER URINARY TRACT UNSPECIFIED
714.0	RHEUMATOID ARTHRITIS
731.0	OSTEITIS DEFORMANS WITHOUT BONE TUMOR
731.3	MAJOR OSSEOUS DEFECTS
733.00	OSTEOPOROSIS UNSPECIFIED
733.01 - 733.09	SENILE OSTEOPOROSIS - OTHER OSTEOPOROSIS
733.10 - 733.19	PATHOLOGICAL FRACTURE UNSPECIFIED SITE - PATHOLOGICAL FRACTURE OF OTHER SPECIFIED SITE
733.90	DISORDER OF BONE AND CARTILAGE UNSPECIFIED
733.96	STRESS FRACTURE OF FEMORAL NECK
733.97	STRESS FRACTURE OF SHAFT OF FEMUR
733.98	STRESS FRACTURE OF PELVIS
775.4	HYPOCALCEMIA AND HYPOMAGNESEMIA OF NEWBORN
775.7	LATE METABOLIC ACIDOSIS OF NEWBORN
775.81 - 775.89	OTHER ACIDOSIS OF NEWBORN - OTHER NEONATAL ENDOCRINE AND METABOLIC DISTURBANCES
775.9	UNSPECIFIED ENDOCRINE AND METABOLIC DISTURBANCES SPECIFIC TO THE FETUS AND NEWBORN
780.01	COMA
780.31 - 780.39	FEBRILE CONVULSIONS (SIMPLE), UNSPECIFIED - OTHER CONVULSIONS
780.71	CHRONIC FATIGUE SYNDROME
780.79	OTHER MALAISE AND FATIGUE
780.97	ALTERED MENTAL STATUS
781.0	ABNORMAL INVOLUNTARY MOVEMENTS
781.7	TETANY
785.50 - 785.59	SHOCK UNSPECIFIED - OTHER SHOCK WITHOUT TRAUMA
787.01 - 787.03	NAUSEA WITH VOMITING - VOMITING ALONE
787.20	DYSPHAGIA, UNSPECIFIED
787.21	DYSPHAGIA, ORAL PHASE
787.22	DYSPHAGIA, OROPHARYNGEAL PHASE
787.23	DYSPHAGIA, PHARYNGEAL PHASE
787.24	DYSPHAGIA, PHARYNGOESOPHAGEAL PHASE
787.29	OTHER DYSPHAGIA
788.42	POLYURIA
963.5	POISONING BY VITAMINS NOT ELSEWHERE CLASSIFIED
996.81	COMPLICATIONS OF TRANSPLANTED KIDNEY
996.83	COMPLICATIONS OF TRANSPLANTED HEART
996.87	COMPLICATIONS OF TRANSPLANTED ORGAN INTESTINE
V42.0	KIDNEY REPLACED BY TRANSPLANT
V42.1	HEART REPLACED BY TRANSPLANT
V56.0	AFTERCARE INVOLVING EXTRACORPOREAL DIALYSIS
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}

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}

Jacobs, Demott, Finley, Horvat, Kasten, Tilzer. Laboratory Test Handbook. 3rd edition. Lexi-Comp, Inc; 1994:159.

CMD Clinical Laboratory Workgroup

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 #12, 10/17/2008
Revision #11, 10/01/2008
Revision #10, 10/01/2007
Revision #9, 10/01/2006
Revision #8, 10/01/2005
Revision #7, 06/27/2005
Revision #6, 11/22/2004
Revision #5, 10/01/2004
Revision #4, 10/01/2003
Revision #3, 08/30/2002
Revision #2, 02/15/2001
Revision #1, 10/15/1999

Revision History Explanation ^{back to top}

Revision #12, 10/17/2008
ICD-9 codes 733.96, 733.97 and 733.98 were inadvertently omitted from the revision history. The codes have been effective since 10/1/2008. This revision becomes effective on 10/17/2008.

Revision #11, 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 203.02, 203.12, 203.82, 204.02, 204.12, 204.22, 204.82, 204.92, 205.02, 205.12, 205.22, 205.32, 205.82, 205.92, 206.02, 206.12, 206.22, 206.82, 206.92, 207.02, 207.12, 207.22, 207.82, 208.02, 208.12, 208.22, 208.82, 208.92, 275.5 and 571.42. This revision becomes effective 10/01/2008.

Revision #10, 10/01/2007
Under AMA/CPT & ADA/CDT Copyright Statement the copyright date was changed from 2006 to 2007. Under CMS National Coverage Policy changed the publication number for the referenced Change Request from “100-8” to now read “100-08”. Under Indications and Limitations of Coverage and/or Medical Necessity, statement #2 added verbiage. 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. ICD-9 code 787.2 was extended to a 5th digit to now read 787.20, 787.21, 787.22, 787.23, 787.24, and 787.29. This revision becomes effective 10/01/2007.

Revision #9, 10/01/2006
Under AMA/CPT & ADA/CDT Copyright Statement section of the policy, 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, 518.7, 731.3, 775.81-775.89, and 780.97. The verbiage was changed for ICD-9 codes 403.01, 403.11, 403.90, 403.91, 404.02, 404.12, and 404.92. Under Sources of Information and Basis for Decision deleted “Existing Palmetto GBA Part B Policy” and the references were placed in the AMA citation format. This policy was reviewed for annual validation. This revision becomes effective 10/01/2006.

Revision #8, 10/01/2005
Under AMA/CPT & ADA/CDT Copyright Statement section of the policy, the copyright date was changed from 2004 to 2005. Under Bill Type Codes section of the policy, bill type 73x was added. Under ICD-9 Codes That Support Medical Necessity section of the policy, ICD-9 276.5 was expanded to 276.50, 276.51, and 276.52. ICD-9 code 585 expanded to 585.1-585.9. Also there were verbiage changes to the 403 codes. Under Advisory Committee Meeting Notes section the word effected was changed to affected. These changes become final on 10/01/2005.

Revision #7, 06/27/2005
Converted the Local Medical Review Policy to a Local Coverage determination. This becomes effective 06/14/2005.

Under CMS National Coverage Policy verbiage changed for Title XVIII of the Social Security Act, section 1862 (a)(1)(A). Deleted Change Request 2592 and added Change Request 3010. Under Revenue Codes changed 0300 to 030X. Under ICD-9 Codes That Support Medical Necessity added multiple ICD-9 codes identified with the subscript date 06/27/05. Under Documentation Requirements verbiage changed. Under Advisory Committee Notes verbiage changed. This revision becomes effective 06/27/05.

Revision #6, 11/22/2004
Under AMA CPT Copyright Statement section of the 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 NOTE related to Appeal rights, as this information will appear on the Palmetto GBA web site under Appeals information. These revisions become effective 11/22/2004.

Revision #5, 10/01/2004
Under AMA CPT Copyright Statement changed the copyright date from 2003 to 2004. Added the 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 and added ICD-9 codes 252.01-252.08, 276.7, 276.8 and 403.11. Extended ICD-9 code 588.8 to 5th digit- 588.81-588.89. Extended ICD-9 code 780.3 to 5th digit 780.31-780.39. These changes become effective 10/01/2004.

Revision #4, 10/01/2003
The copyright date was changed under section AMA CPT Copyright Statement. CMS Pub. 100-8, Medicare Program Integrity, Transmittal 44, dated July 25, 2003, Change Request 2592 was added under the section CMS National Coverage Policy. These changes will become effective 10/01/2003.

Revision #3 08/30/02
Under Type of Bill Code section of this policy, Critical Access Hospital (85x) has been added. This change becomes effective 10/01/2002.

Revision #2 02/15/2001

Revision #1 10/15/1999

This LCD was converted from an LMRP on 6/13/2005

Reason for Change ^{back to top}

ICD9 Addition/Deletion

Last Reviewed On Date ^{back to top}

10/03/2008

Medicare Coverage Database

LCD for Ionized Calcium (L1308)