LCD : Potassium (Serum) (L1642)

LCD for Potassium (Serum) (L1642)

Contractor Information

Contractor Name

BlueCross BlueShield of Tennessee (Riverbend Government Benefits Administrator)

Contractor Number

00390

Contractor Type

LCD Information

LCD ID Number

L1642

LCD Title

Potassium (Serum)

Contractor's Determination Number

1642

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.

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 12/27/1996

Original Determination Ending Date

Revision Effective Date

For services performed on or after 07/28/2005

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

A blood test which reveals the body's potassium level and is helpful in diagnosing potassium imbalance as related to medical disorders. If utilized appropriately, it assists the provider in determining the response to current treatment and/or present status of condition.

Medicare will provide coverage for serum potassium laboratory studies that are medically necessary based on specific symptoms, illnesses or injuries.

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
15x	Hospital-intermediate care - level I
16x	Hospital-intermediate care - level II
17x	Hospital-intermediate care - level III
18x	Hospital-swing beds
19x	Hospital-reserved for national assignment
21x	SNF-inpatient, Part A
22x	SNF-inpatient or home health visits (Part B only)
23x	SNF-outpatient (HHA-A also)
24x	SNF-other (Part B)
25x	SNF-intermediate care - level I
26x	SNF-intermediate care - level II
27x	SNF-intermediate care - level III
28x	SNF-swing beds
29x	SNF-reserved for national assignment
31x	HHA-inpatient (including Part A)
32x	HHA-inpatient or home health visits (Part B only)
33x	HHA-outpatient (HHA-A also)
34x	HHA-other (Part B)
35x	HHA-intermediate care - level I
36x	HHA-intermediate care - level II
37x	HHA-intermediate care - level III
38x	HHA-swing beds
39x	HHA-reserved for national assignment
41x	Religious Nonmedical Health Care Institution (RNHCI) hospital-inpatient (including Part A) (all references to Christian Science (CS) is obsolete eff. 8/00 and replaced with RNHCI)
42x	RNHCI hospital-inpatient or home health visits (Part B only)
43x	RNHCI hospital-outpatient (HHA-A also)
44x	RNHCI hospital-other (Part B)
45x	RNHCI hospital-intermediate care - level I
46x	RNHCI hospital-intermediate care - level II
47x	RNHCI hospital-intermediate care - level III
48x	RNHCI hospital-swing beds
49x	RNHCI hospital-reserved for national assignment
51x	CS extended care-inpatient (including Part A) OBSOLETE eff. 7/00 - implementation of Religious Nonmedical Health Care Institutions (RNHCI)
52x	RNHCI extended care-inpatient or home health visits (Part B only) (eff. 7/00); prior to 7/00 Christian Science (CS)
53x	RNHCI extended care-outpatient (HHA-A also) (eff. 7/00); prior to 7/00 referenced CS
54x	RNHCI extended care-other (Part B)(eff. 7/00); prior to 7/00 referenced CS
55x	RNHCI extended care-intermediate care - level I (eff. 7/00) prior to 7/00 referenced CS
56x	RNHCI extended care-intermediate care - level II (eff. 7/00) prior to 7/00 referenced CS
57x	RNHCI extended care-intermediate care - level III (eff. 7/00) prior to 7/00 referenced CS
58x	RNHCI extended care-swing beds (eff. 7/00) prior to 7/00 referenced CS
59x	RNHCI extended care-reserved for national assignment (eff. 7/00); prior to 7/00 referenced CS
61x	Intermediate care-inpatient (including Part A)
62x	Intermediate care-inpatient or home health visits (Part B only)
63x	Intermediate care-outpatient (HHA-A also)
64x	Intermediate care-other (Part B)
65x	Intermediate care-intermediate care - level I
66x	Intermediate care-intermediate care - level II
67x	Intermediate care-intermediate care - level III
68x	Intermediate care-swing beds
69x	Intermediate care-reserved for national assignment
71x	Clinic-rural health
72x	Clinic-hospital based or independent renal dialysis facility

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

84132

POTASSIUM; SERUM

ICD-9 Codes that Support Medical Necessity

250.00 - 259.9*	DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - UNSPECIFIED ENDOCRINE DISORDER
276.50	VOLUME DEPLETION, UNSPECIFIED
276.51	DEHYDRATION
276.52	HYPOVOLEMIA
276.7	HYPERPOTASSEMIA
276.8	HYPOPOTASSEMIA
276.9	ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED
401.0 - 405.99	MALIGNANT ESSENTIAL HYPERTENSION - OTHER UNSPECIFIED SECONDARY HYPERTENSION
410.00	ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED
427.0	PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
427.31	ATRIAL FIBRILLATION
427.32	ATRIAL FLUTTER
427.61	SUPRAVENTRICULAR PREMATURE BEATS
427.89	OTHER SPECIFIED CARDIAC DYSRHYTHMIAS
428.0	CONGESTIVE HEART FAILURE UNSPECIFIED
580.0 - 589.9*	ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - SMALL KIDNEY UNSPECIFIED
781.0	ABNORMAL INVOLUNTARY MOVEMENTS
788.41	URINARY FREQUENCY
788.42	POLYURIA
788.43	NOCTURIA
*latest code updates

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

Medicare documentation for all serum potassium monitoring, which is covered by Medicare, is expected to indicate the clear and concise medical necessity within the patient’s medical record should chart review become necessary. If documentation is requested submit:

History and Physical
M.D. orders/progress notes
Diagnosis/Reason for Test
Test results
Itemization of charges

Appendices

Utilization Guidelines

Sources of Information and Basis for Decision

Carrier Policy

Medical texts

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

End Date of Comment Period

Start Date of Notice Period

11/27/1996

Revision History Number

1642a

Revision History Explanation

10/01/2004 Annual ICD-9 Code Update: Insert 252.00, 252.01, 252.02, 252.08, 588.81, 588.89. Replace 252.0 with 252.00, 252.01, 252.02, 252.08. Replace 588.8 with 588.81 and 588.89. All revisions found in field ICD-9 Codes that Support Medical Necessity.

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

07/24/2002 Formatted

02/21/2001 updated ICD-9 codes with the 2001 ICD-9 & CPT code books

This LCD was converted from an LMRP on 7/27/2005

09/04/2005 - This policy was updated by the ICD-9 2005-2006 Annual Update.

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.

09/03/2007 - This policy was updated by the ICD-9 2007-2008 Annual Update.

09/27/2007 - Frequently Asked Questions restored to Appendices.

2/18/2008 - The description for Bill code 21 was changed

3/20/2008 - Frequently Asked Questions removed from Appendices