Highmark Medicare Advantage Medical Policy in West Virginia
Section: Laboratory
Number: L-15
Topic: Diagnostic Tests for Chronic Renal Disease Patients
Effective Date: January 1, 2008
Issued Date: April 21, 2008

General Policy

For services on or after June 15, 2009, see policy N-162.

Various diagnostic tests used in the evaluation of chronic renal disease patients.

Indications and Limitations of Coverage

Diagnostic tests are essential in monitoring the progress of chronic renal disease patients. The following list of tests and frequencies constitutes the level and types of tests that are covered:

Guidelines for laboratory studies for ESRD patients undergoing hemodialysis, intermittent peritoneal dialysis (IPD), continuous cycling peritoneal dialysis (CCPD).

* The laboratory studies listed below are included in the dialysis facility composite rate and are reimbursed under Part A:

Per Treatment

All hematocrit (85013, 85014) or hemoglobin (85018) and clotting time (85345-85348) tests furnished incident to dialysis treatments

Per Week

Prothrombin time (85610) for patients on anticoagulant therapy

Creatinine; blood (82565)

Urea Nitrogen (84520, 84525)

* BUN tests furnished more than once per week but no more than 13 times per calendar quarter are included under the composite rate payment rule. Tests in excess of 13 may be billed if they are medically necessary. A diagnosis of ESRD alone is not sufficient medical documentation. The nature of the illness (diagnosis, complaint, or symptom) must be present on the claim.

Per Month

Albumin; serum (82040)

Electrolyte panel (80051)
Basic metabolic panel (calcium, ionized) (80047)

Hepatic function panel (80076)

Basic metabolic panel (80048)

Lactate Dehydrogenase (LD-LDH) (83615, 83625)

Calcium; total (82310-82331)

Phosphatase, alkaline (84075-84080)

Carbon Dioxide (bicarbonate) (82374)

Phosphorus Inorganic (phosphate) 84100)

CBC (85025, 85027)

Potassium; serum (84132)

Chlorides; blood (82435)

Transferase; aspartate amino (AST) (SGOT) (84450)

Comprehensive metabolic panel (80053)

Total Protein (84155, 84160)
 

* Following are tests not included in the composite rate which may be paid at the frequency shown for ESRD patients undergoing hemodialysis, IPD, CCPD. Tests in excess of this frequency require medical documentation. A diagnosis of ESRD alone is not sufficient medical documentation. The nature of the illness (diagnosis, complaint, or symptom) requiring the performance of the test must be present on the claim. These tests are reimbursable.

Per Three Months

Aluminum (82108)

Ferritin (82728)

Guidelines for laboratory studies for ESRD patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

* The laboratory studies listed below are included in the composite rate and are reimbursed under Part A:

Per Month

Albumin; serum (82040)

 Total protein (84155, 84160)
Basic metabolic panel (calcium, ionized) (80047)

Creatinine; blood (82565)

Basic metabolic panel (80048)

Dialysate Protein (89240)
Calcium; total (82310-82331)

Electrolyte panel (80051)

Carbon dioxide (82374)

HCT (85013, 85014)

Comprehensive metabolic panel (80053)

Hepatic function panel (80076)

Hgb (85018)

Potassium; serum (84132)

Lactate Dehydrogenase (LD-LDH) (83615, 83625)

Sodium; serum (84295)

Magnesium (83735)

Transferase; aspartate amino (AST) (SGOT)(84450)

Phosphatase, alkaline (84075-84080)

Urea Nitrogen; quantitative (84520)
Phosphorus inorganic (84100)

Urea Nitrogen; semiquantitative (84525)

* Following are tests not included in the composite rate which may be paid at the frequency shown for ESRD patients undergoing CAPD. Tests in excess of this frequency require medical documentation. A diagnosis of ESRD alone is not sufficient medical documentation. The nature of the illness (diagnosis, complaint, or symptom) requiring the performance of the test must be present on the claim. These tests are reimbursable.

Per Three Months

WBC (85048)

RBC (85041)

Platelet count (85049)

Per Six Months

Residual renal function (84999)

24 hour urine volume (81050)

Tests in excess of the specified frequencies require medical documentation. A diagnosis of ESRD alone is not sufficient medical documentation. The nature of the illness (diagnosis, complaint, or symptom) requiring the performance of the tests must be present on the claim.

Procedure Codes

Coding Guidelines

Publications

References

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS Online Manual Pub. 100-4, Chapter 16, Section 40.6, 40.6.1, 40.6.2, 40.6.2.1, 40.6.2.2, 40.7, 60.1.3, 60.1.4

CMS Online Manual Pub. 100-2, Chapter 11, Section 70.3

CMS Online Manual Pub. 100-4, Chapter 4, Section 70

CMS Online Manual Pub. 100-3, Chapter 1, Section 190.10

CMS Program Memorandum AB-97-23

www.cms.gov
www.medicare.gov

Attachments

Procedure Code Attachments

Diagnosis Codes

Glossary




This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.