LCD for Magnesium (L1340)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L1340 

 

LCD Title 

Magnesium 

 

Contractor's Determination Number 

1340 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2006 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 

Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section excludes coverage of items or services that are not 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, Section 1862 (a)(7). This section prohibits Medicare payment for any expenses on items and services incurred for routine physical examinations.

Title XVIII of the Social Security Act, Section 1833 (e). This section prohibits Medicare payment for any claim that lacks the necessary information to process the claim.
 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
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South Carolina
Tennessee
Texas
Utah
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Vermont
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West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 02/20/1997  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 07/27/2005  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

Magnesium is a mineral required by the body for the use of adenosine triphosphate (ATP) as a source of energy. It is also necessary for neuromuscular irritability and blood clotting. Magnesium deficiency produces neuromuscular disorders. It may cause weakness, tremors, tetany, and convulsions. Hypomagnesemia is associated with hypocalcemia, hypokalemia, long-term hyperalimentation, intravenous therapy, diabetes mellitus, especially during treatment of ketoacidosis; alcoholism and other types of malnutrition; malabsorption; hyperparathyroidism; dialysis; pregnancy; and hyperaldosteronism. The following are other conditions which may cause magnesium deficiencies:

 

  • Renal loss of magnesium occurs with cisplatinum therapy.
  • Hypomagnesemia may also be induced by amphotericin toxicity.


Magnesium deficiency is described with cardiac arrhythmias. The concept that magnesium may cause arrhythmias is repeatedly expressed.



Indications

 

  • Utilization of certain cardiac drugs which cause adverse effects in the presence of low magnesium (i.e., Quinidine, Procainamide, and Norpace). Patients taking these drugs should have their magnesium checked approximately once every six months.
  • Long term parenteral nutrition. Patients on long term parenteral nutrition that are otherwise asymptomatic should have a serum magnesium checked monthly.
  • Malabsorption syndromes: The frequency should depend on the severity of the syndrome, but once the patient’s level is stabilized, a monthly check should be adequate.
  • Renal loss secondary to diuretic use should be followed on a six-month basis.
  • Chronic alcoholism, diabetic acidosis, and renal tubular acidosis. These patients should be followed on an as needed basis according to their symptomatology. Without symptoms, they should be checked no more than annually.
  • Chronic diarrhea, otherwise unexplained and persistent should have a magnesium check once it is stabilized on a 2-3 month basis.
  • Prolonged nasogastric suction greater than five days should have a magnesium check every two to three weeks.
  • Cisplatinum use, checked on a monthly basis during the therapeutic regimen.
  • Patients receiving IV magnesium therapy for a low serum level should have it checked indicated by the dose and renal function of the patient.
  • Patients with hypocalcemia should have a magnesium check. If the hypocalcemia persists, the level should probably be checked on a six-month basis as long as the patient does not have symptoms of arrhythmias which would warrant closer follow up.
  • Lethargy and confusion which are not otherwise explained. Once a patient has been diagnosed with processes such as Alzheimer or psychotic depression, etc., there is no indication to follow their magnesium level on a regular basis.
  • Patients receiving oral magnesium in the face of impaired renal function should have this checked on a monthly basis.
  • Pre-eclampsia
  • Unexplained muscular paralysis.
  • Neuromuscular irritability.
  • Blood clotting.
  • Supraventricular and ventricular arrhythmias, not otherwise classified.


 

 

Coverage Topic 

Lab Services
 

 

Coding Information

Bill Type Codes: 

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

 

 

Revenue Codes: 

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 

 

83735

MAGNESIUM

 

 

ICD-9 Codes that Support Medical Necessity 

 

250.10 - 250.13

DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.20 - 250.23

DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.30 - 250.33

DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.40 - 250.43

DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.50 - 250.53

DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.60 - 250.63

DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.70 - 250.73

DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.80 - 250.83

DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED

250.90 - 250.93

DIABETES WITH UNSPECIFIED COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH UNSPECIFIED COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED

252.00 - 252.1

HYPERPARATHYROIDISM, UNSPECIFIED - HYPOPARATHYROIDISM

252.8 - 252.9

OTHER SPECIFIED DISORDERS OF PARATHYROID GLAND - UNSPECIFIED DISORDER OF PARATHYROID GLAND

255.10

HYPERALDOSTERONISM, UNSPECIFIED

255.11

GLUCOCORTICOID-REMEDIABLE ALDOSTERONISM

255.12

CONN'S SYNDROME

255.13

BARTTER'S SYNDROME

255.14

OTHER SECONDARY ALDOSTERONISM

259.3

ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED

260

KWASHIORKOR

261

NUTRITIONAL MARASMUS

262

OTHER SEVERE PROTEIN-CALORIE MALNUTRITION

263.0

MALNUTRITION OF MODERATE DEGREE

263.8 - 263.9

OTHER PROTEIN-CALORIE MALNUTRITION - UNSPECIFIED PROTEIN-CALORIE MALNUTRITION

275.2

DISORDERS OF MAGNESIUM METABOLISM

275.40 - 275.49

UNSPECIFIED DISORDER OF CALCIUM METABOLISM - OTHER DISORDERS OF CALCIUM METABOLISM

276.2

ACIDOSIS

276.4

MIXED ACID-BASE BALANCE DISORDER

276.50

VOLUME DEPLETION, UNSPECIFIED

276.51

DEHYDRATION

276.52

HYPOVOLEMIA

276.7 - 276.8

HYPERPOTASSEMIA - HYPOPOTASSEMIA

276.9

ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED

278.8

OTHER HYPERALIMENTATION

286.9

OTHER AND UNSPECIFIED COAGULATION DEFECTS

289.59

OTHER DISEASES OF SPLEEN

293.0 - 293.1

DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE - SUBACUTE DELIRIUM

298.9

UNSPECIFIED PSYCHOSIS

303.90 - 303.93

OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE UNSPECIFIED DRINKING BEHAVIOR - OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE IN REMISSION

307.1

ANOREXIA NERVOSA

307.20

TIC DISORDER UNSPECIFIED

307.22

CHRONIC MOTOR OR VOCAL TIC DISORDER

307.50

EATING DISORDER UNSPECIFIED

307.51

BULIMIA NERVOSA

307.52

PICA

307.59

OTHER DISORDERS OF EATING

333.2

MYOCLONUS

333.3

TICS OF ORGANIC ORIGIN

336.1

VASCULAR MYELOPATHIES

345.60 - 345.61

INFANTILE SPASMS WITHOUT INTRACTABLE EPILEPSY - INFANTILE SPASMS WITH INTRACTABLE EPILEPSY

359.5

MYOPATHY IN ENDOCRINE DISEASES CLASSIFIED ELSEWHERE

359.9

MYOPATHY UNSPECIFIED

410.00 - 410.92

ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE

411.81

ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION

415.11 - 415.19

IATROGENIC PULMONARY EMBOLISM AND INFARCTION - OTHER PULMONARY EMBOLISM AND INFARCTION

427.0 - 427.2

PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - PAROXYSMAL TACHYCARDIA UNSPECIFIED

427.31 - 427.32

ATRIAL FIBRILLATION - ATRIAL FLUTTER

427.41 - 427.42

VENTRICULAR FIBRILLATION - VENTRICULAR FLUTTER

427.5

CARDIAC ARREST

427.60 - 427.69

PREMATURE BEATS UNSPECIFIED - OTHER PREMATURE BEATS

427.81 - 427.89

SINOATRIAL NODE DYSFUNCTION - OTHER SPECIFIED CARDIAC DYSRHYTHMIAS

427.9

CARDIAC DYSRHYTHMIA UNSPECIFIED

429.79

CERTAIN SEQUELAE OF MYOCARDIAL INFARCTION NOT ELSEWHERE CLASSIFIED OTHER

429.89

OTHER ILL-DEFINED HEART DISEASES

458.0 - 458.1

ORTHOSTATIC HYPOTENSION - CHRONIC HYPOTENSION

458.29

OTHER IATROGENIC HYPOTENSION

458.8 - 458.9

OTHER SPECIFIED HYPOTENSION - HYPOTENSION UNSPECIFIED

536.2

PERSISTENT VOMITING

579.3

OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION

579.8

OTHER SPECIFIED INTESTINAL MALABSORPTION

579.9

UNSPECIFIED INTESTINAL MALABSORPTION

584.5 - 584.9

ACUTE RENAL FAILURE WITH LESION OF TUBULAR NECROSIS - ACUTE RENAL FAILURE UNSPECIFIED

585.1

CHRONIC KIDNEY DISEASE, STAGE I

585.2

CHRONIC KIDNEY DISEASE, STAGE II (MILD)

585.3

CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)

585.4

CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)

585.5

CHRONIC KIDNEY DISEASE, STAGE V

585.6

END STAGE RENAL DISEASE

585.9

CHRONIC KIDNEY DISEASE, UNSPECIFIED

586

RENAL FAILURE UNSPECIFIED

588.81*

SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN)

588.89*

OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION

593.81

VASCULAR DISORDERS OF KIDNEY

632

MISSED ABORTION

634.10 - 637.82

SPONTANEOUS ABORTION UNSPECIFIED COMPLICATED BY DELAYED OR EXCESSIVE HEMORRHAGE - LEGALLY UNSPECIFIED ABORTION COMPLETE WITH UNSPECIFIED COMPLICATION

638.0 - 638.9

FAILED ATTEMPTED ABORTION COMPLICATED BY GENITAL TRACT AND PELVIC INFECTION - FAILED ATTEMPTED ABORTION WITHOUT COMPLICATION

639.1

DELAYED OR EXCESSIVE HEMORRHAGE FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES

639.3

RENAL FAILURE FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES

639.4

METABOLIC DISORDERS FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES

639.5

SHOCK FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES

639.6

EMBOLISM FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES

639.8 - 639.9

OTHER SPECIFIED COMPLICATIONS FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES - UNSPECIFIED COMPLICATION FOLLOWING ABORTION OR ECTOPIC AND MOLAR PREGNANCIES

640.00 - 669.94

THREATENED ABORTION UNSPECIFIED AS TO EPISODE OF CARE - UNSPECIFIED COMPLICATION OF LABOR AND DELIVERY POSTPARTUM CONDITION OR COMPLICATION

673.20 - 673.24

OBSTETRICAL BLOOD-CLOT EMBOLISM UNSPECIFIED AS TO EPISODE OF CARE - OBSTETRICAL BLOOD-CLOT EMBOLISM POSTPARTUM

728.9

UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA

760.0

MATERNAL HYPERTENSIVE DISORDERS AFFECTING FETUS OR NEWBORN

760.1

MATERNAL RENAL AND URINARY TRACT DISEASES AFFECTING FETUS OR NEWBORN

760.4

MATERNAL NUTRITIONAL DISORDERS AFFECTING FETUS OR NEWBORN

760.71

NOXIOUS INFLUENCES AFFECTING FETUS OR NEWBORN VIA PLACENTA OR BREAST MILK, ALCOHOL

760.8 - 763.9

OTHER SPECIFIED MATERNAL CONDITIONS AFFECTING FETUS OR NEWBORN - UNSPECIFIED COMPLICATION OF LABOR AND DELIVERY AFFECTING FETUS OR NEWBORN

780.01 - 780.02

COMA - TRANSIENT ALTERATION OF AWARENESS

780.09

ALTERATION OF CONSCIOUSNESS OTHER

780.2

SYNCOPE AND COLLAPSE

780.31 - 780.39

FEBRILE CONVULSIONS (SIMPLE), UNSPECIFIED - OTHER CONVULSIONS

780.71 - 780.79

CHRONIC FATIGUE SYNDROME - OTHER MALAISE AND FATIGUE

781.0

ABNORMAL INVOLUNTARY MOVEMENTS

781.7

TETANY

783.0

ANOREXIA

783.21

LOSS OF WEIGHT

783.22

UNDERWEIGHT

783.3

FEEDING DIFFICULTIES AND MISMANAGEMENT

783.9

OTHER SYMPTOMS CONCERNING NUTRITION METABOLISM AND DEVELOPMENT

785.0

TACHYCARDIA UNSPECIFIED

785.50 - 785.51

SHOCK UNSPECIFIED - CARDIOGENIC SHOCK

785.59

OTHER SHOCK WITHOUT TRAUMA

790.6

OTHER ABNORMAL BLOOD CHEMISTRY

794.31

NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG)

794.4

NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF KIDNEY

796.2

ELEVATED BLOOD PRESSURE READING WITHOUT DIAGNOSIS OF HYPERTENSION

799.4

CACHEXIA

958.4

TRAUMATIC SHOCK

995.20 - 995.29

UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE - UNS