Parathyroid Hormone, Phosphorous, Calcium and Magnesium Testing
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Reimbursement criteria and coding guidance for serum intact parathyroid hormone (PTH) and selected calcium, phosphorus and magnesium laboratory tests for Blue Cross Blue Shield - New Mexico members and participating providers.
Reimbursement Information edited for clarity; testing frequencies reordered and 'one time testing' for hypoparathyroidism changed to 'annual testing' and then later clarified in other edits.
Note 2 describing the conditions pseudohypoparathyroidism and related disorders was added.
Combined separate criteria into a single criterion that lists all appropriate testing indications for intact PTH serum testing.
Coverage Criteria for Intact PTH and Related Tests
Reimbursable and non-reimbursable test criteria
Conditions and situations in which serum intact PTH testing may be reimbursable and tests that are not reimbursable:
ANY of the following
- For individuals with abnormal calcium levels.
- During the initial assessment and diagnosis of hypoparathyroidism for individuals with signs of hypoparathyroidism (see Note 1).
- For individuals with osteoporosis or low bone mass.
- For individuals who have undergone parathyroidectomy.
- Annual testing for individuals diagnosed with hyperparathyroidism who have not undergone parathyroidectomy.
- Annual testing for individuals with multiple endocrine neoplasia type 2A (MEN2A) or familial medullary thyroid carcinoma.
ALL of the following
- Grade 3 CKD: one test every twelve months.
- Grade 4 or Grade 5 CKD: one test every three months.
ALL of the following
- Individuals < 18 years: one test every three months.
- Individuals ≥ 18 years: one test every year.
ALL of the following
- Serum, blood, or fecal magnesium testing.
- Serum phosphorus or phosphate testing.
- Urine phosphorus or phosphate testing.
- Serum total calcium, serum ionized calcium, or urine calcium testing.
Covered indications and frequencies for intact PTH serum testing
Intact parathyroid hormone (PTH) serum testing MEETS COVERAGE CRITERIA in any of the following situations:
ANY of the following
- For individuals with abnormal calcium levels.
- One time testing for the diagnosis of hypoparathyroidism for individuals with signs of hypoparathyroidism (Note 1).
- For individuals with osteoporosis or low bone mass.
- For individuals who have undergone parathyroidectomy.
- One test every year for individuals diagnosed with hyperparathyroidism who have not undergone parathyroidectomy.
ALL of the following
- Grade 3 CKD: one test every twelve months.
- Grade 4 or Grade 5 CKD: one test every three months.
- One time testing for individuals with multiple endocrine neoplasia type 2A (MEN2A) or familial medullary thyroid carcinoma.
ALL of the following
- Individuals < 18 years: every three months.
- Individuals ≥ 18 years: every year (see Note 2).
Follow the policy's covered indications and frequencies for intact serum PTH
Intact serum parathyroid hormone (PTH) reimbursement is limited to the listed covered indications and specified testing frequencies; tests outside these indications are not reimbursable. The policy consolidates covered indications including abnormal calcium, diagnosis of hypoparathyroidism, osteoporosis/low bone mass, post‑parathyroidectomy care, hyperparathyroidism follow‑up, CKD‑based monitoring, MEN2A/familial medullary thyroid carcinoma, and pseudohypoparathyroidism‑related disorder schedules.
- Covered indications and frequencies are enumerated in the Reimbursement Information and must be met for reimbursement.
- Tests performed for conditions not described in the listed indications are not reimbursable.
Coding and Frequency Guidance
| No codes listed |
Provider Documentation and Claims Submission
Submit accurate documentation and use valid code combinations on claims
Providers must submit accurate documentation of services performed and file claims using valid code combinations from approved code sets; claims are subject to code edits and may require additional documentation upon request.
- Code claims according to industry standard coding guidelines (e.g., CPT, ICD‑10‑CM, HCPCS) and payer/contract rules.
- Be prepared to provide additional documentation upon request as claims are subject to review and code‑edit protocols.
Order intact PTH only at policy‑specified frequencies
Adhere to the specific testing frequencies noted in the policy when ordering intact PTH to ensure reimbursement; the policy explicitly lists frequency requirements for CKD stages, hyperparathyroidism, pseudohypoparathyroidism, and other covered indications.
- CKD monitoring: Grade 3 — one test every 12 months; Grade 4 or 5 — one test every 3 months.
- Hyperparathyroidism (no parathyroidectomy): one test every year.
- Pseudohypoparathyroidism/related disorders: <18 years — every 3 months; ≥18 years — annually.
- One‑time testing allowed for diagnosis of hypoparathyroidism and for MEN2A/familial medullary thyroid carcinoma as specified.
Key Definitions and Clinical Signs
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