FINAL

METRAHEALTH PART B MEDICARE JACKSON MS (10250)

LOCAL MEDICAL REVIEW POLICY

SUBJECT: Alanine Aminotransferase (ALT)(SGPT)
POLICY NUMBER: FMR-9525
DESCRIPTION: Alanine Aminotransferase is found predominantly in the liver. Lesser quantities are found in the kidneys, heart, and skeletal muscle. Injury or disease affecting the liver parenchyma win cause a release of this hepatocellular enzyme into the bloodstream, thus elevating serum ALT levels. Generally, most ALT elevations are caused by liver dysfunction. Therefore this enzyme is not only sensitive, but also quite specific in indicating hepatocellular disease.
POLICY TYPE: Local Medical Necessity Policy
HCPCS SECTION BENEFIT CATEGORY: Pathology and Laboratory
HCPCS CODES: 84460 Transferase; Alanine Amino (ALT)(SGPT)
HCFA'S NATIONAL POLICY: None
INDICATIONS AND LIMITATIONS OF COVERAGE: Alanine aminotransferase is more specific for liver injury than AST (SGOT). Useful for hepatic cirrhosis, and other liver disease. The ALT test is occasionally used as an aid in the differential diagnosis of liver disease by means of the AST/ ALT ratio.
COVERED ICD-9 CODES: 570 - 573.9 Liver disease
  864.00 - 864.19 Injury to liver
  Note: Diagnostic codes are to be used at their highest level of specificity. Fourth and fifth digits should be utilized when they are available.
  EMC and hard copy claims will be monitored for appropriateness and frequency.
REASONS FOR NONCOVERAGE: Medicare does not provide coverage for tests obtained for screening purposes or for tests obtained for medically unnecessary indications.
  Follow-up testing performed at a frequency greater than is necessary for the reasonable medical management of the patient's condition is not covered.
NONCOVERED ICD-9 CODE(S): N/A
SOURCES OF INFORMATION: 1. Ravel, R., Clinical Laboratory Medicine, 5th Edition, pg. 305.
  2. Jacobs, D.S., and Tilzer, L.L., Laboratory Test Handbook, 3rd Edition, 1994, pg. 100.
CODING GUIDELINES: The disease or symptom for which the test is ordered must be correctly coded in appropriate ICD-9 format.
  This test is included in the list of automatable multi-channel chemistry tests specified in the Local Medical Review Policy entitled "Automated Multi-Channel Tests - Clinical Chemistry Tests", published in Medicare Newsletter #169, January 1995. When two or more tests are performed on the same day using automated multi-channel equipment, you should bill them as part of the automated panel and not bill them separately.
  A single test may be billed separately.
 
Place of Service: Office (11)
  Independent Laboratory (81)
DOCUMENTATION REQUIREMENTS: Utilization of this procedure for other than the diagnoses listed will require additional supporting documentation from the ordering physician.
  Documentation in the patient's record must indicate medical necessity to be covered by Medicare.
  Payments can be made on a REVIEW basis for diagnosis other than those listed above. The utility and need for these services must be documented to be:
 
  1. Safe and effective.
  2. Appropriate for the diagnosis
  3. Not for convenience
  4. A need not met by another service already performed.
  Documentation should include but is not limited to:
 
  1. Peer reviewed medical literature.
  2. AMA DATTA reports.
  3. Policy of specialty groups.
  4. Office notes, lab reports.
OTHER COMMENTS: This policy will be utilized in conducting prepayment (procedure to diagnosis) and postpayment reviews.
  Nonphysician Claims (i.e., independent clinical labs) - Documentation supporting the medical necessity of this item such as ICD-9 codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary.
RATIONALE FOR CREATING POLICY: FMR 95 revealed overutilization of this lab test without clear, concise medical indications.
CAC NOTES: Meeting date policy discussed: 09/26/95
  There were no comments received during comment period (09/26/95-11/10/95).
START DATE OF COMMENT PERIOD: 09/26/95
START DATE OF NOTICE PERIOD: 09/26/95
EFFECTIVE DATE: 01-10-96
REVISION DATE:  
REVISION NUMBER:  

This policy does not reflect the sole opinion of the carrier or Carrier Medical Director. Although the final decision rests with the carrier, this policy was developed in cooperation with the Carriers Advisory Committee, which includes representatives from:

Additional Distribution: Medical Directors in Region IV

Published in Medicare News