(Reproduced by permission from Medicare Focus, April, 2000)
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, 18X, 22X, 23X, 24X, 28X, 71X, 72X, 73X, 83X 85X
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 examination or as part of a routine physical checkup, without signs, symptoms or the presence of an illness. The panel covered by this local medical review policy when done as a screening test would not be a covered Medicare benefit.
Panel must include:
Carbon dioxide (82374)
ICD-9-CM Codes That Support Medical Necessity
One of the following covered ICD-9-CM diagnosis codes must be linked to the appropriate procedure.
By nature of the structure of the panel, one ICD-9-CM code will define medical necessity for the entire panel.
Diseases of Other Endocrine Glands
250.10 - 250.13
250.20 - 250.23
250.30 - 250.33
250.40 - 250.43
250.80 - 250.83
252.0 - 252.9
253.5 - 253.6
255.0 - 255.9
263.0 - 263.1
Other Metabolic and Immunity Disorders
276.0 - 276.9
290.0 - 290.9
401.0 - 405.99
410.00 - 410.12 Revised per Medicare Focus April, 2002
410.90 Revised per Medicare Focus April, 2002
410.91 Revised per Medicare Focus April, 2002
410.92 Revised per Medicare Focus April, 2002
Diseases of Pulmonary Circulation
Other Forms of Heart Disease
Diseases of Veins and Lymphatics, and Other Diseases of Circulatory System
Other Diseases of Respiratory System
Diseases of Esophagus, Stomach, and Duodenum
Other Diseases of Intestines and Peritoneum
Other Diseases of Digestive System
Diseases of the Genitourinary System
Complications Mainly Related to Pregnancy
Rheumatism Excluding the Back
Symptoms, Signs, and Ill-defined Conditions
Other and Unspecified Effects of External Causes
Persons With A Condition Influencing Their Health Status
Persons Encountering Health Services For Specific Procedures and Aftercare
Persons Encountering Health Services In Other Circumstances
HCPCS Section and Benefit Category
Pathology and Laboratory
HCFA National Coverage 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 reasonable and medically necessary, i.e., reasonable and necessary are those tests used in the diagnosis and management of illness or 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.
Title XVIII of the Social Security Act, Section 1861(s). These sections outline coverage for drugs and biologicals and services and supplies.
Reasons 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.In this circumstance, one of the following ICD-9-CM diagnosis codes must be linked to the procedure code: V70.0-V70.9, V82.9.
Services will always be denied which are considered:
routine screening; or
a program exclusion; or
never medically necessary; or
Otherwise not covered.
Non-covered ICD-9-CM Diagnosis Codes
Any code not listed in the "ICD-9-CM Codes That Support Medical Necessity" section of this policy.
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) 2000
Report the principal diagnosis (Form Locator 67) to your highest degree of certainty. Secondary diagnosis codes (Form Locator 68-75) should include the patient's presenting symptoms and any other medical conditions that may effect the patient's care (Refer to the May 1999 issue of Medicare Focus).
Reconsiderations and Appeals - Claims resubmitted with a different diagnosis code must include medical record documentation to justify the diagnosis code change. Submission with diagnoses other than those listed in the "ICD-9-CM Codes That Support Medical Necessity" section of this policy, will be individually reviewed by this Intermediary for medical necessity.
Documentation supporting the medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary.
All coverage criteria must be documented in the patient's medical record and made available to Medicare upon request. This information should be generally submitted on reconsideration only (or with the claim if the services are unusual or if denial is anticipated).
ICD-9-CM diagnosis codes are required on claim.
If documentation is requested for review, submit the following:
History and Physical
Physician orders/progress notes
Itemization of charges
This local medical review policy revises the previously published local medical review policy Electrolyte Panel published in the February 1998 issue of Medicare Focus.
This policy should be interpreted to incorporate future changes in the ICD-9-CM or CPT/HCPCS coding systems such that its original intent and scope will not be substantively changed.
All Physicians' Current Procedural Terminology (CPT) five-digit numeric codes and descriptions are Copyright© 1999 American Medical Association. All rights reserved.
All International Classification of Diseases, 9TH REVISION, Clinical Modification (ICD-9-CM) codes and descriptions are copyright© 1998 Medicode, Inc.
Start Date of Comment Period
December 27, 1999
Start Date of Notice Period
February 1, 1998
April 1, 2000
Original Effective Date
March 1, 1998
Revised Effective Date
May 1, 2000
This policy does not reflect the sole opinion of the Intermediary/Medical Director. Although the final decision rests with the Intermediary, this policy has developed in conjunction with the other Intermediaries and other Intermediary policies.