LCD for Prostatic Acid Phosphatase (PAP) (L1428)

 

Contractor Information

Contractor Name 

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator) 

Contractor Number 

00390 

Contractor Type 

FI 

 

LCD Information

LCD ID Number 

L1428 

 

LCD Title 

Prostatic Acid Phosphatase (PAP) 

 

Contractor's Determination Number 

1428 

 

AMA CPT / ADA CDT Copyright Statement 

CPT codes, descriptions and other data only are copyright 2007 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.

Medicare Carrier Manual, section 5114.1-5114.3

42CFR410.32. Diagnostic tests may only be ordered by a treating physician (or other treating practitioner acting within the scope of their license and Medicare requirements). 

 

Primary Geographic Jurisdiction 

New Jersey
Tennessee
 

 

Secondary Geographic Jurisdiction 

Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
 

 

Oversight Region 

Region IV
 

 

 

Original Determination Effective Date 

For services performed on or after 10/16/1997  

 

Original Determination Ending Date 

 

 

Revision Effective Date 

For services performed on or after 12/08/2005  

 

Revision Ending Date 

 

 

Indications and Limitations of Coverage and/or Medical Necessity 

Prostatic Acid Phosphatase testing is useful in:

 

  • staging of prostatic carcinoma in conjunction with other parameters;
  • diagnosis of metastatic adenocarcinoma of the prostate and/or extension beyond the prostatic capsule;
  • monitoring therapy; and
  • following the patient’s response to therapy.



HCFA Publication 14-3, Medicare Carrier Manual, section 5114.1-5114.3-42CRD410.32. Diagnostic tests may only be ordered by a treating physician (or other treating practitioner acting within the scope of their license and Medicare requirements). 

 

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

031X

Laboratory pathological-general classification

 

 

CPT/HCPCS Codes 

 

84066

PHOSPHATASE, ACID; PROSTATIC

 

 

ICD-9 Codes that Support Medical Necessity 

Please be aware it is not enough to link the procedure code to a correct, payable ICD-9-CM diagnosis code. The diagnosis must be present for the procedure to be paid, but in addition, the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the beneficiary's medical record must support the medical necessity for the test(s) provided. (See also, Reasons for Denial; Coding Guidelines; and Documentation Requirements below.)

185

MALIGNANT NEOPLASM OF PROSTATE

196.5

SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

196.6

SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRAPELVIC LYMPH NODES

196.8

SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF MULTIPLE SITES

198.5

SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

198.82

SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS

222.2

BENIGN NEOPLASM OF PROSTATE

233.4

CARCINOMA IN SITU OF PROSTATE

236.5

NEOPLASM OF UNCERTAIN BEHAVIOR OF PROSTATE

239.5

NEOPLASM OF UNSPECIFIED NATURE OF OTHER GENITOURINARY ORGANS

790.93

ELEVATED PROSTATE SPECIFIC ANTIGEN [PSA]

995.20

UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

995.27

OTHER DRUG ALLERGY

995.29

UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE

V10.46

PERSONAL HISTORY OF MALIGNANT NEOPLASM OF PROSTATE

V67.51

FOLLOW-UP EXAMINATION FOLLOWING COMPLETED TREATMENT WITH HIGH-RISK MEDICATION NOT ELSEWHERE CLASSIFIED

 

 

Diagnoses that Support Medical Necessity 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity 

 

 

 

 

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation 

 

 

Diagnoses that DO NOT Support Medical Necessity 

 

 

General Information

Documentation Requirements 

1. Documentation supporting the medical necessity of these tests, such as ICD-9 diagnosis codes or comparable narrative should be submitted on the claim. Failure to do so may result in denial of the claim.

2. The ordering physician should retain in the patient's medical record, history and physical, examination notes documenting evaluation and management of one of the Medicare covered conditions/diagnoses, with relevant clinical signs/symptoms or abnormal laboratory test results, appropriate to one of the covered indications. The patient's clinical record should further indicate changes/alterations in medications prescribed for the treatment of the patient's condition. There must be an attending/treating physician's order for each test documented in the patient's medical/clinical record. Documentation must be submitted to Medicare upon request.
 

 

Appendices 

LINK TO QUESTIONS AND ANSWERS (COMMENTS) ABOUT THIS
POLICY:
Frequently Asked Questions


 

 

Utilization Guidelines 

 

 

Sources of Information and Basis for Decision 

Carrier Policy

Laboratory Test Handbook; Jacobs, Demott, et al.; 1996

CMD Clinical Laboratory Workgroup

1996 CPT Physicians' Current Procedural Terminology, American Medical Association 

 

Advisory Committee Meeting Notes 

This policy does not reflect the sole opinion of the contractor or contractor medical director. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from appropriate specialties as well as provider (facility) representatives. 

 

Start Date of Comment Period 

08/01/1997 

 

End Date of Comment Period 

 

 

Start Date of Notice Period 

09/15/1997 

 

Revision History Number 

049-97g 

 

Revision History Explanation 

01/10/2003 Added 12x to Type of Bill Code

07/24/2002 Formatted

01/08/2001 updated codes with CPT and ICD-9 2001 code books

This LCD was converted from an LMRP on 12/7/2005

7/2/2006 - The description for Bill code 14 was changed

09/04/2006 - This policy was updated by the ICD-9 2006-2007 Annual Update.

10/05/2007 - Frequently Asked Questions restored to Appendices. 

 

Reason for Change 

Other
 

Last Reviewed On Date 

10/05/2007 

 

Related Documents 

Article(s)
A37892 - Prostatic Acid Phosphatase (PAP)

 

LCD Attachments 

FAQ - Comment and Response (953 bytes)

 

Other Versions 

Updated on 09/26/2006 with effective dates 12/08/2005 - N/A

Updated on 09/01/2006 with effective dates 12/08/2005 - N/A

Updated on 07/02/2006 with effective dates 12/08/2005 - N/A

Updated on 12/07/2005 with effective dates 12/08/2005 - N/A

Updated on 12/07/2005 with effective dates 01/10/2003 - 12/07/2005

Updated on 03/11/2003 with effective dates 01/10/2003 - N/A

Updated on 02/15/2003 with effective dates 01/10/2003 - N/A

Updated on 01/09/2003 with effective dates 01/10/2003 - N/A

Updated on 10/04/2002 with effective dates 07/24/2002 - 01/09/2003