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Superseded Local Coverage Determination (LCD)

Serum Phosphorus

L34022

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Contractor Information

Contractor Name	Contract Type	Contract Number	Jurisdiction	States
First Coast Service Options, Inc.	A and B MAC	09101 - MAC A	J - N	Florida
First Coast Service Options, Inc.	A and B MAC	09102 - MAC B	J - N	Florida
First Coast Service Options, Inc.	A and B MAC	09201 - MAC A	J - N	Puerto Rico Virgin Islands
First Coast Service Options, Inc.	A and B MAC	09202 - MAC B	J - N	Puerto Rico
First Coast Service Options, Inc.	A and B MAC	09302 - MAC B	J - N	Virgin Islands

LCD Information

Document Information

LCD ID
L34022

LCD Title
Serum Phosphorus

Proposed LCD in Comment Period
N/A

Source Proposed LCD
N/A

Original Effective Date
For services performed on or after 10/01/2015

Revision Effective Date
For services performed on or after 11/11/2021

Revision Ending Date
N/A

Retirement Date
N/A

Notice Period Start Date
N/A

Notice Period End Date
N/A

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Issue

Issue Description

Section 50.1 in the Internet-Only Manual 100-04, Chapter 8 was revised with CR 12079 to 50.1.1. The reference in the LCD has been updated with this revision.

CMS National Coverage Policy

This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Serum Phosphorus. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for Serum Phosphorus and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site.

Internet Only Manual (IOM) Citations:

CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
- Chapter 11, Section 20 Renal Dialysis Items and Services, Section 20.2 Laboratory Services, Section 30 Home Dialysis, Section 40 G. Renal Dialysis Services Furnished During the Creation or Revision of a Vascular Access, Section 100.5 Renal Dialysis Services Included in the AKI Payment Rate
- Chapter 15, Section 80 Requirements for Diagnostic X-Ray, Diagnostic Laboratory, and Other Diagnostic Tests
CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
- Chapter 1, Part 3, Section 190.10 Laboratory Tests - CRD Patients
CMS IOM Publication 100-04, Medicare Claims Processing Manual,
- Chapter 8, Section 50.1 Laboratory Services Included in the End Stage Renal Disease Prospective Payment System ESRD PPS, Section 60 Separately Billable ESRD Items and Services, and Section 60.1 Lab Services
- Chapter 16 Laboratory Services, Section 10 Background, Section 50.5.1 Jurisdiction of Referral Laboratory Services, Section 90.1 Laboratory Tests Utilizing Automated Equipment, Section 90.2 Organ or Disease Oriented Panels
- Chapter 23, Section 40 Clinical Diagnostic Laboratory Fee Schedule
CMS IOM Publication 100-08, Medicare Program Integrity Manual,
- Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare 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 1862(a)(7). This section excludes routine physical examinations.

Federal Register References:

CFR, Title 42, Volume 2, Chapter IV, Part 410.32 Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Compliance with the provisions in this LCD may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

Phosphorus levels are determined by calcium metabolism, parathyroid hormone, and to a lesser degree by intestinal absorption. Normal serum phosphorus is 2.5-4.5mg/dl. Serum phosphate levels help to detect endocrine, skeletal, and calcium disorders, and aid in the diagnosis of renal disorders and acid-base imbalance.

Covered Indications

Serum phosphorus testing will be considered medically reasonable and necessary under either of the two following circumstances:

1. Evaluation of patients with signs and symptoms of hypophosphatemia. Patients with mild hypophosphatemia usually have no clinical findings. The clinical findings below usually occur when the phosphate deficit is severe:

Anorexia
Apprehension
Bone pain
Confusion
Encephalopathy
Hemolysis
Hypercaliuria
Mental obtundation
Muscle weakness and soreness
Nausea
Osteomalacia
Paresthesias
Platelet dysfunction
Rhabdomyolysis
Seizures
Thrombocytopenia

Conditions in which serum phosphorus testing may be medically reasonable and necessary include, but are not limited to, the following which are related to hypophosphatemia:

Decreased phosphate ingestion or absorption:

Malnutrition: alcoholism, starvation
Vitamin D deficiency
Malabsorption syndrome
Hyperalimentation without phosphate supplements

Increased utilization or consequence of metabolism:

Pregnancy
Recovery from malnutrition or diabetic ketoacidosis: insulin and glucose therapy
Respiratory alkalosis: salicylate poisoning, gram-negative bacteremia
Lactate, sodium bicarbonate, or sodium chloride infusion
Absorption by bone following parathyroiectomy

Excess losses of phosphate:

Dialysis
Diuretic therapy
Primary hyperparathyroidism
Renal tubular defects: congenital, after renal transplant, toxic, and diuretic phase following acute renal failure or burns
Oral antacid therapy
Hypomagnesemia

2. Evaluation of patients with hyperphosphatemia. Patients with hyperphosphatemia usually have no clinical symptoms per se. Symptoms may arise, however, from underlying conditions. Some signs of hyperphosphatemia can include, but are not limited to, the following:

serum phosphorus level greater than 4.5mg/dl on two fasting blood levels
skeletal lesions on x-ray
elevation of serum creatinine and alkaline phosphatase

Conditions in which serum phosphate testing may be medically reasonable and necessary include, but are not limited to, the following which are related to hyperphosphatemia:

Excess phosphate from exogenous sources:
- Ingestion of dairy products
- Ingestion of phosphate salts or use of phosphate enemas in patients with renal disease
- Hpervitaminosis D
- Sarcoidosis
Excess phosphate from endogenous sources:
- Metabolic or respiratory acidosis
- Skeletal lesion, local: myeloma, Paget’s disease, and metastic carcinoma
- Skeletal lesion, diffuse: prolonged skeletal immobilization, severe hyperparathyroidism secondary to renal disease
- Phosphate release from tissue destruction or ischemia: irradiation or chemotherapy hemolysis, lactic acidosis
Impaired excretion of phosphate: renal disease, hypoparathyroidism

Even though a patient has a condition stated above, it is not expected that a serum phosphorus test be performed frequently for stable chronic symptoms that are associated with that disease.

Tests useful in the differential diagnosis include repeat serum phosphorus, alkaline phosphatase, calcium, parathyroid hormone, and skeletal x-ray.

Limitations

Refer to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 11, Section 20.2 Laboratory Services for guidance regarding laboratory services furnished to individuals for the treatment of end stage renal disease (ESRD ).

As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under which the item or service is considered reasonable and necessary.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes

Changes	Fields Changed
	N/A

Associated Information

Sources of Information

Bibliography

Open Meetings

Contractor Advisory Committee (CAC) Meetings

MAC Meeting Information URLs

Proposed LCD Posting Date

Comment Period Start Date

Comment Period End Date

Reason for Proposed LCD

Contact for Comments on Proposed LCD

Coding Information

ICD-10-CM Codes that Support Medical Necessity

ICD-10-CM Codes that DO NOT Support Medical Necessity

Additional ICD-10 Information

General Information

Associated Information

Please refer to the Local Coverage Article: Billing and Coding: Serum Phosphorus (A57650) for documentation requirements, utilization parameters and all coding information as applicable.

Sources of Information

First Coast Service Options, Inc., reference LCD number(s) – L29017, L29278, L29474

Anderson, D.M. (2002). Mosby’s medical dictionary (6th ed.). St. Louis, MO: Mosby.

Beers, M. H., Berkow, R. (Ed.), (2005). Water, Electrolyte, Mineral, and Acid-Base Metabolism. The Merck Manual, Sec. 2, Ch. 12. Retrieved July 29, 2005.

Rodriguez-Benot, A. (2005). Mild hyperphosphatemia and mortality in hemodialysis patients [Abstract]. American Journal of Kidney Disease, 46(1): 68-77.

Bibliography

N/A

Revision History Information

Revision History Date	Revision History Number	Revision History Explanation	Reasons for Change
11/11/2021	R9	LCD revised and published on 12/9/2021 to make minor formatting changes.	Typographical Error
11/11/2021	R8	LCD revised and published on 11/11/2021 to revise the title of section 50.1 in the IOM 100-04, Chapter 8 IOM citation. This revision is in response to CR 12079. Minor formatting changes made throughout the LCD.	Other (Revision in response to CR 12079)
01/08/2019	R7	Revision Number: 5 Publication: November 2019 Connection LCR A/B2019-075 Explanation of Revision: Based on Change Request (CR) 10901, the LCD was revised to remove all billing and coding and all language not related to reasonable and necessary provisions (“Bill Type Codes,” “Revenue Codes,” “CPT/HCPCS Codes,” “ICD-10 Codes that Support Medical Necessity,” “Documentation Requirements” and “Utilization Guidelines” sections of the LCD) and place them into a newly created billing and coding article. During the process of moving the ICD-10-CM diagnosis codes to the billing and coding article, the ICD-10-CM diagnosis code ranges were broken out and listed individually. In addition, the Social Security Act, Code of Federal Regulations, and IOM reference sections were updated. The effective date of this revision is for claims processed on or after January 8, 2019, for dates of service on or after October 3, 2018. At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this LCD.	Other (Revision based on CR10901)
10/01/2018	R6	Revision Number: 4 Publication: September 2018 Connection LCR A/B2018-074 Explanation of revision: Based on CR 10847 (Annual 2019 ICD-10-CM Update), the LCD was revised. Deleted ICD-10-CM diagnosis code M79.1. Added ICD-10-CM diagnosis code range M79.11-M79.18. In addition, an Asterisk explanation was added in the “ICD-10 Codes that Support Medical Necessity”section of the LCD under “ Group 1: Asterisk” for the ICD-10-CM code Z98.890 that contains additional information beyond the CPT descriptor. The effective date of this revision is based on date of service. 10/01/2018: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this LCD.	Revisions Due To ICD-10-CM Code Changes
12/07/2017	R5	Revision Number: 3 Publication: December 2017 Connection LCR A/B2017-052 Explanation of Revision: Based on an annual review of the LCD, it was determined that some of the italicized language in the “Indications and Limitations of Coverage and/or Medical Necessity” and “Utilization Guidelines” sections of the LCD do not represent direct quotation from CMS sources listed in the LCD; therefore, this LCD is being revised to assure consistency with the CMS sources. The effective date of this revision is based on date of service. 12/07/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy.	Other (Revisions to the LCD were based on an annual review conducted on 8/31/2017.)
05/12/2017	R4	Revision Number: 2 Publication: June 2017 Connection LCR A/B2017-023 Explanation of Revision: Based on CR 8776, the following verbiage was removed from the “CPT/HCPCS Codes” section of the LCD: “Per CR 8572, beginning in CY 2014, payment for most laboratory tests (except for molecular pathology tests) will be packaged under the OPPS, therefore the clinical laboratory tests listed below, for TOB 13X (outpatient hospital), are packaged in this setting.” The effective date of this revision is for claims processed on or after 05/12/2017, for dates of service on or after 01/01/2014.	Provider Education/Guidance
10/01/2016	R3	Revision history date corrected should be 2016 and not 2015.	Other
10/01/2015	R2	Revision Number: 1 Publication: October 2016 Connection LCR A/B2016-097 Explanation of Revision: Based on CR 9677 (Annual 2017 ICD-10-CM Update) the LCD was revised. Deleted diagnosis code K90.4 and changed ICD-10-CM diagnosis code range K90.0-K90.4 to ICD-10-CM diagnosis code range K90.0-K90.49; added ICD-10-CM diagnosis code M62.84; deleted ICD-10-CM diagnosis code Z98.89* and added ICD-10-CM diagnosis code Z98.890. Deleted statement below codes with asterisk for Z98.89. The effective date of this revision is based on date of service.	Revisions Due To ICD-10-CM Code Changes
10/01/2015	R1	03/04/015 - The language and/or ICD-10-CM diagnoses were updated to be consistent with the current ICD-9-CM LCD’s language and coding.	Provider Education/Guidance

Associated Documents

Attachments
N/A

Related Local Coverage Documents
Articles
A57650 - Billing and Coding: Serum Phosphorus

Updated On	Effective Dates	Status
08/31/2023	11/11/2021 - 08/31/2023	Retired	View
12/03/2021	11/11/2021 - N/A	Superseded	You are here
11/05/2021	11/11/2021 - N/A	Superseded	View
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Serum Phosphorus

Document Note

Note History

Contractor Information

LCD Information

Document Information

Issue

CMS National Coverage Policy

Coverage Guidance

Proposed Process Information

Coding Information

Bill Type Codes

Revenue Codes

CPT/HCPCS Codes

Group 1

ICD-10-CM Codes that Support Medical Necessity

Group 1

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Additional ICD-10 Information

General Information

Revision History Information

Associated Documents

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