(Reproduced by permission from Medicare Focus, April, 2000)

Medicare Part A
Local Medical Review Policy
Renal Function Panel

Policy Number:



This chemistry panel is a disease oriented panel used in the diagnosis and management of illnesses and injuries causing changes in renal function. 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

Revenue Codes


Indications and Limitations of Coverage and/or Medical Necessity


This chemistry panel may be used in the diagnosis and management of illnesses and injuries affecting renal function.


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.



Renal Function Panel

Panel must include:

Albumin (82040)
Calcium (82310)
Carbon dioxide (bicarbonate) (82374)
Chloride (82435)
Creatinine (82565)
Glucose (82947)
Phosphorus inorganic (phosphate) (84100)
Potassium (84132)
Sodium (84295)
Urea Nitrogen (BUN) (84520)

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.

Diagnosis Definition

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
250.40 - 250.43
252.0 - 252.9
Hypertensive Disease
403.00 - 403.01
403.10 - 403.11
403.90 - 403.91
404.00 - 404.03
404.12 - 404.13
404.92 - 404.93
405.01 - 405.99 Revised per Medicare Focus March, 2002

Other Diseases of Digestive System
Diseases of the Genitourinary System
580.0 - 580.9
581.0 - 581.9
582.0 - 582.9
583.0 - 583.9
584.5 - 584.9
585 - 587
588.0 - 589.9
Other Diseases of Urinary System
Complications Mainly Related to Pregnancy
642.00 - 642.94
Congenital Anomalies
753.0 - 753.3
Injury to Blood Vessels
902.40 - 902.49
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:


experimental; or


cosmetic; or


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) Sections 2070, 5114
AMA Physicians' Current Procedural Terminology (CPT) 2000

Coding Guidelines

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 affect 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 Requirements

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


Nurses notes


Test results


Itemization of charges


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

April 1, 2000

Original 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 was developed in conjunction with the other Intermediaries and other Intermediary policies.