(Reproduced by permission from Medicare Focus, February, 1998, pp. 23 - 26. Updates noted.)

Medicare Part A
Local Medical Review Policy
Comprehensive Metabolic Panel

Policy Number: A98-07

Description

80053

This chemistry panel is a disease oriented panel and used in the diagnosis and management of various illnesses and injuries. It is one of several panels which replace the previous automated multi-channel tests. The panel must consist of the stated tests and all tests must be performed. Any additional tests must be ordered as a separate test or as one of the other organ or disease oriented panels.

Type of Bill: 12X, 13X, 14X, 21X, 72X, 73X

Revenue Codes: 30X, 31X

Indications and Limitations of Coverage and/or Medical Necessity

This chemistry panel may be used in the diagnosis and management of various illnesses and injuries.

Screening tests are defined as those tests done in the course of an annual physical checkup or as a matter of "routine" without signs, symptoms or the presence of an illness. This panel, when done as a screening test, would not be a covered Medicare benefit.

HCPCS Codes:

ICD-9-CM Codes That Support Medical Necessity

Diagnosis Definition

Presently any ICD-9-CM code may be used to state medical necessity. By nature of the structure of the panel one ICD-9-CM code will define medical necessity for the entire panel.

Category:

Pathology and Laboratory

HCFA's National Policy

Title XVIII of the Social Security Act, section 1862(a)(1)(A). This section allows coverage and payment for only those services that are considered to be medically reasonable and necessary, i.e., reasonable and necessary are those tests used in the diagnosis and management of illness and injury or to improve the function of a malformed body part.

Title XVIII of the Social Security Act, section 1862(a)(7). This section excludes routine physical examinations.

Reason for Denial

Tests performed during annual physical examinations or other routine screening situations without signs, symptoms or illness will result in denial as a non-covered benefit.

ICD-9-CM Codes: (Codes that are never covered)

V70.0 - V70.9

Sources of Information

Medicare Carriers Manual (HCFA Pub. 14-3) 2070, 5114
AMA Physicians' Current Procedural Terminology (CPT) 1998
PMIC AB 97-17, New Panels Approved by Common Procedural Terminology, September 1997

Documentation Required

ICD-9 diagnosis codes are required on claim.

Medical records must clearly document the medical necessity for the test and the frequency of the test.

If documentation is requested for review, submit the following:

• History and Physical;
• Physician orders/progress notes documenting medical necessity;
• Diagnosis;
• Exam results;
• Itemization of charges.

Approval

This policy is being adapted from the Carrier policy. It does not represent the sole opinion of the Intermediary/Medical Director. This policy was developed in consultation with the medical community via the Carrier Advisory Committee.

Approval Dates