Indications and Limitations of Coverage
Diagnostic Laboratory Tests
This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.
Laboratory tests are essential to monitor the progress of CRD patients. The following list and frequencies of tests constitute the level and types of routine laboratory tests that are covered. Bills for other types of tests are considered nonroutine. Routine tests at greater frequencies must include medical justification. Nonroutine tests generally are justified by the diagnosis. The routinely covered regimen includes the following tests.
- All hematocrit or hemoglobin and clotting time tests furnished incident to dialysis treatments.
- Prothrombin time for patients on anticoagulant therapy
- Serum Creatinine
Per Week or Thirteen Per Quarter
- Serum Calcium
- Serum Potassium
- Serum Chloride
- Serum Bicarbonate
- Serum Phosphorous
- Total Protein
- Serum Albumin
- Alkaline Phospatase
- AST, SGOT
Guidelines for tests other than those routinely performed include:
- Serum Aluminum - one every 3 months
- Serum Ferritin - one every 3 months
The following tests for hepatitis B are covered when patients first enter a dialysis facility: Hepatitis B surface antigen (HBsAg), Anti-HBs. Coverage of future testing in these patients depends on their serologic status and on whether they have been successfully immunized against hepatitis B virus. The following table summarizes the frequency of serologic surveillance for hepatitis B. Tests furnished according to this table do not require additional documentation and are paid separately because payment for maintenance dialysis treatments does not take them into account.
| Frequency of Screening
|| Vaccination and Serologic Status
|| HBsAg Patients
|| Anti-HBs Patients
|| HBsAg Carrier
|| Anti-HBs-Positive 1
|| Anti-HBs-Positive 1
|| Low Level or No Anti-HBs
At least 10 sample ration units by radioimmunoassay or positive by enzyme immunoassay.
Patients who are in the process of receiving hepatitis B vaccines, but have not received the complete series, should continue to be routinely screened as susceptible. Between one and six months after the third dose, all vaccines should be tested for anti-HBs to confirm their response to the vaccine. Patients who have a level of anti-HBs of at least 10 sample ratio units (SRUs) by radioimmunoassay (RIA) or who are positive by enzyme immunoassay (EIA) are considered adequate responders to vaccine and need only be tested for anti-HBs annually to verify their immune status. If anti-HBs drops below 10 SRUs by RIA or is negative by EIA, a booster dose of hepatitis B vaccine should be given.
Laboratory tests are subject to the normal coverage requirements. If the laboratory services are performed by a free-standing facility, be sure it meets the conditions of coverage for independent laboratories.