CurrentCapital BluecrossPolicy AHS - G2164 - Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing, 1 = Initial Presentation

Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing

Policy defines coverage criteria and limitations for serum/urine testing of intact parathyroid hormone (PTH), calcium (total and ionized), phosphorus/phosphate, and magnesium, including frequencies for specific conditions (CKD, hyperparathyroidism, pseudohypoparathyroidism, MEN2A) and tests that do not meet coverage.

Policy Summary

PayerCapital Bluecross

PolicyParathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing

Policy CodePolicy AHS - G2164 - Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing, 1 = Initial Presentation

Change TypeNo material change

Effective DateMar 1, 2019

Next Review Date

Key ActionFor covered PTH tests, providers must document the clinical indication matching one of the covered situations and the date of prior parathyroidectomy if applicable.

SourceLink

POLICY UPDATE CHANGES

This policy has no material clinical or coverage changes in this update.

8Explicit covered PTH indications listed

5Tests not covered for wellness/general exam

3CKD and pseudohypoparathyroidism frequency rules

Society Guidelines Referenced

Coverage Summary

This policy (Policy Number: AHS - G2164 - Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing, 1 = Initial Presentation; effective 2019-03-01; last reviewed 2025-08-01) defines coverage criteria and limitations for serum and urine testing of intact parathyroid hormone (PTH), total and ionized calcium, phosphorus/phosphate, and magnesium, and lists applicable CPT codes for these analytes.

Serum intact PTH testing is covered for a set of specified clinical indications including: abnormal calcium levels, one-time diagnosis of hypoparathyroidism when signs are present, evaluation in osteoporosis/low bone mass, post-parathyroidectomy care, surveillance for known hyperparathyroidism (annual), monitoring in CKD (stage-specific frequencies), one-time testing for MEN2A/familial medullary thyroid carcinoma, and routine intervals for pseudohypoparathyroidism (pediatric and adult schedules).

Several tests are explicitly not covered when ordered for wellness or general exams without abnormal findings: serum/blood/fecal magnesium, serum or urine phosphorus/phosphate, serum total or ionized calcium or urine calcium, and parathyroid hormone testing for asymptomatic hyperparathyroidism screening; testing for truncated PTH metabolites is also not covered.

Primary hyperparathyroidism albumin-adjusted serum calciumRepeat testing if ≥2.6 mmol/L; or ≥2.5 mmol/L with features

KDIGO CKD monitoring intervalsG3a-G3b: Ca/Phosphate every 6–12 mo; PTH based on baseline/progression. G4: Ca/Phosphate every 3–6 mo; PTH every 6–12 mo. G5: Ca/Phosphate every 1–3 mo; PTH every 3–6 mo

ASBMR post-transplant phosphate action thresholdMeasure phosphorus daily first week; treat persistent phosphate <2.5 mg/dL with supplementation

Number of explicit covered PTH indications8

Medically Necessary — Serum intact PTH testing

Medically Necessary - Serum intact parathyroid (PTH) testing

Serum intact parathyroid (PTH) 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 (see Note 1).
See Note 1 for signs: hypocalcemia; elevated serum phosphorus; low calcitriol; hypercalciuria; abnormal magnesium.
For individuals with osteoporosis or low bone mass.
For individuals who have undergone parathyroidectomy.

Not Covered / Does Not Meet Coverage Criteria

ANY of the following

Serum intact parathyroid (PTH) testing to screen for asymptomatic hyperparathyroidism DOES NOT MEET COVERAGE CRITERIA.
Tests that do not meet coverage when presenting for wellness/general exam without abnormal findings
- Serum, blood, or fecal magnesium testing.
- Serum phosphorus or phosphate testing.
- Urine phosphorus or phosphate testing.

Guideline-based Indications and Monitoring Recommendations

Extracted recommendations from professional society guidelines describing when to test and recommended monitoring intervals:

ANY of the following

Measure serum calcium, phosphate, PTH, and alkaline phosphatase at least once in adults with GFR <45 mL/min/1.73 m2 (CKD G3b-G5) to determine baseline values (KDIGO 2012 recommendation 3.3.1).
Monitor serum levels of calcium, phosphate, PTH, and alkaline phosphatase beginning in CKD G3a (KDIGO 2017 recommendation 3.1.1).
For CKD monitoring intervals (KDIGO reasonable monitoring intervals):
- G3a-G3b: Serum Calcium — Every 6-12 months.

CPT / HCPCS Codes

Applicable CPT/HCPCS Procedure CodesCPTCovered

82310	Calcium; total
82330	Calcium; ionized
82340	Calcium; urine quantitative, timed specimen
83735	Magnesium
83970	Parathormone (parathyroid hormone)
84100	Phosphorus inorganic (phosphate)
84105	Phosphorus inorganic (phosphate); urine

Provider Actions & Billing Rules

Documentation Required

Document indication for PTH testing

Document the clinical indication that matches one of the covered situations for PTH testing (e.g., abnormal calcium, signs of hypoparathyroidism, osteoporosis/low bone mass, post-parathyroidectomy, hyperparathyroidism surveillance, CKD stage, MEN2A/familial medullary thyroid carcinoma, pseudohypoparathyroidism). If the individual has had prior parathyroidectomy, record the date of the surgery in the chart.

Required indication must match a covered situation listed in the policy (see covered PTH indications).
For hypoparathyroidism, document specific signs (hypocalcemia, elevated serum phosphorus, low calcitriol, hypercalciuria, abnormal magnesium).
If post-parathyroidectomy, include the date of surgery.

Billing Rule

Frequency limits for PTH testing

Evidence & References

The policy cites an evidence base addressing pre-analytical and analytical variability in PTH assays, studies demonstrating large between-method differences with clinical implications, and multiple professional guideline recommendations that define when to test and appropriate monitoring intervals across CKD, hypoparathyroidism, and primary hyperparathyroidism.

Revision History

2019-03-01effective

Effective date

2025-08-01last_reviewLatest

Last review

Policy Summary

PayerCapital Bluecross

PolicyParathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing

Policy CodePolicy AHS - G2164 - Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing, 1 = Initial Presentation

Change TypeNo material change

Effective DateMar 1, 2019

Next Review Date

Key ActionFor covered PTH tests, providers must document the clinical indication matching one of the covered situations and the date of prior parathyroidectomy if applicable.

SourceLink

On This Page

One test every year for individuals diagnosed with hyperparathyroidism and who have not undergone parathyroidectomy.

Chronic kidney disease (CKD) frequency

For individuals with Grade 3 CKD: One test every twelve months.
For individuals with 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.

Pseudohypoparathyroidism and related disorders frequency

For individuals who are less than 18 years of age: One test every three months.
For individuals who are 18 years of age or older: One test every year.

Serum total calcium, serum ionized calcium, or urine calcium testing.

Serum parathyroid hormone testing.

Testing serum for truncated parathyroid hormone metabolites (e.g., amino-terminal and carboxy-terminal fragments) DOES NOT MEET COVERAGE CRITERIA.

G3a-G3b: Serum Phosphate — Every 6-12 months.

G3a-G3b: PTH — Based on baseline level and CKD progression.

G4: Serum Calcium — Every 3-6 months.

G4: Serum Phosphate — Every 3-6 months.

G4: PTH — Every 6-12 months.

G5: Serum Calcium — Every 1-3 months.

G5: Serum Phosphate — Every 1-3 months.

G5: PTH — Every 3-6 months.

G4-G5D: Alkaline Phosphatase Activity — Every 12 months or more frequently if elevated PTH.

ALL of the following

G1T-G3bT: Serum Calcium & Phosphate — Every 6-12 months; PTH once with subsequent intervals based on baseline and progression.
G4T: Serum Calcium & Phosphate — Every 3-6 months; PTH — Every 6-12 months.
G5T: Serum Calcium & Phosphate — Every 1-3 months; PTH — Every 3-6 months.
ASBMR post-transplant: First 3 months: Calcium & Phosphate every 2 weeks; 3 months–1 year: monthly. PTH: first 3 months monthly; 3 months–1 year every 3 months. Total CO2: first 3 months every 2 weeks; 3 months–1 year monthly.
During first week after kidney transplantation, serum phosphorus should be measured daily; treat persistent phosphate <2.5 mg/dL with supplementation (ASBMR).

ALL of the following

Diagnosis confirmed by hypocalcemia with low/undetectable intact PTH on two occasions at least two weeks apart.
Baseline profile: calcium (albumin-corrected or ionized), serum magnesium, phosphorus, creatinine, 25(OH)D, and 24-hour urine creatinine and calcium.
Stable individuals: monitor repeat laboratory profile every 6-12 months; unstable individuals more frequently.
ESE: Calcium and phosphate every 3-6 months at steady state; ionized calcium preferred; PTH testing only for diagnosis or recovery assessment (6-12 months after surgery).

ALL of the following

Initial diagnostic testing in primary care requires albumin-adjusted serum calcium and PTH when features present (symptoms of hypercalcemia, osteoporosis/fragility fracture, renal stone, or incidental albumin-adjusted calcium ≥2.6 mmol/L).
Repeat albumin-adjusted serum calcium at least once in primary care if first measurement is ≥2.6 mmol/L or ≥2.5 mmol/L with features of PHPT; measure PTH when albumin-adjusted calcium is ≥2.6 mmol/L on at least two occasions or ≥2.5 mmol/L on at least two occasions with suspicion.
When measuring PTH, use a random sample concurrent with albumin-adjusted calcium.

ANY of the following

ALL/TLS: include phosphorus and calcium in tumor lysis syndrome panel; monitor vitamin D and calcium status and replete as needed.
Multiple myeloma and other cancers: include serum calcium in baseline and monitoring panels; correct hypocalcemia prior to denosumab and monitor during therapy.
Venetoclax therapy (CLL/SLL): evaluate potassium, uric acid, phosphorus, calcium, creatinine at pre-dose, 6-8 hours, and 24 hours at initial doses and during ramp-up; consider hospitalization for CrCl <80 mL/min at first doses per NCCN.

ANY of the following

AUA: Measure intact PTH as part of screening when primary hyperparathyroidism is suspected; consider calcium in follow-up for renal neoplasms and kidney stones workup.
AACE/ACE (osteoporosis): for secondary osteoporosis evaluation include CMP, 25(OH)D, intact PTH, phosphate, and 24-hour urine for calcium; repeat urine calcium after vitamin D repletion.
SOGC (pregnancy): routine monitoring of serum magnesium not recommended (2014); 2022 guideline recommends magnesium sulfate therapy but does not mention magnesium testing.
AHA/ACC/HFSA (Heart failure 2022): include serum electrolytes (including calcium and magnesium) in standard diagnostic evaluation of HF.
AAP BRUE guidance (2016): do not obtain serum sodium, potassium, chloride, BUN, creatinine, calcium, or ammonia to detect IEM in lower-risk BRUE infants 60 days to <1 year.
AGA (2013 constipation): metabolic tests including calcium generally not recommended for chronic constipation in absence of other features.

Analytical validity concerns for PTH measurement include substantial between-method variation across commercially available assays, interference from truncated PTH fragments, short biological half-life, and important pre-analytical factors such as specimen type, use of EDTA, timing of draw (circadian variation), venipuncture site, and storage conditions.

Major guideline and review sources cited in the policy include the IFCC Working Group on PTH (systematic review of pre-analytical factors and assay variability), KDIGO guidance on CKD/CKD-MBD monitoring, NICE guidance on primary hyperparathyroidism, ASBMR and European hypoparathyroidism consensus statements, and NCCN oncology guidance.

Hypoparathyroidism signsHypocalcemia; elevated serum phosphorus; low calcitriol; hypercalciuria; abnormal magnesium

Pseudohypoparathyroidism and related disordersIncludes PHP1A, PHP1B, PPHP, POH, ACRDYS1, ACRDYS2

Albumin-adjusted serum calciumTotal serum calcium corrected for albumin concentration; used per NICE for PHPT diagnostic thresholds

CKD G stagesG3a, G3b, G4, G5 categories referenced for monitoring frequency per KDIGO

Adhere to the policy frequency limits for covered PTH testing by diagnosis and age.

Primary hyperparathyroidism (surveillance, no parathyroidectomy): one test every year.
Chronic kidney disease (CKD) — Grade 3: one test every 12 months.
CKD — Grade 4 or Grade 5: one test every 3 months.
Pseudohypoparathyroidism and related disorders: <18 years — every 3 months; ≥18 years — every year.

Documentation Required

Hypoparathyroidism diagnosis testing

One-time PTH testing is permitted to diagnose hypoparathyroidism when clinical and biochemical signs are present; document the supporting signs and follow guideline diagnostic criteria.

One-time testing allowed for diagnosis of hypoparathyroidism when signs present.
Document signs per policy Note 1: hypocalcemia; elevated serum phosphorus; low calcitriol; hypercalciuria; abnormal magnesium.
ASBMR diagnostic confirmation requires hypocalcemia with low/undetectable intact PTH on two occasions ≥2 weeks apart for definitive diagnosis; for initial coverage a one-time test is permitted when signs are documented.

Documentation Required

Use guideline-recommended testing based on diagnosis

Order and document testing consistent with guideline-recommended panels for the relevant diagnosis and record the clinical features that justify testing. Include the listed CPT codes when reporting.

Include clinical features (e.g., symptoms of hypercalcemia, osteoporosis/fragility fracture, renal stone, abnormal serum calcium, GFR stage, therapy initiation) in the record to justify testing.
Follow relevant guideline panels (AAES, NICE, KDIGO, NCCN, AACE/ACE) for which analytes to order and monitoring intervals.
Affected procedure codes for tests are listed in the policy CPT/HCPCS section (see procedure code callout).

Prior Authorization

Check payer/Government coverage conflicts

If this policy conflicts with an applicable government (LCD/NCD) or state Medicaid policy, follow the government policy for coverage determinations. Verify Medicare/Medicaid coverage prior to claim submission.

Follow LCD/NCD or state Medicaid policy where it applies instead of this policy.
Verify current Medicare/Medicaid coverage on CMS or state Medicaid websites before submitting claims.

Billing Rule

Procedure code use and reference

Report the exact CPT codes corresponding to the specimen and analyte as listed in the policy's CPT/HCPCS section; select the appropriate code(s) for each specimen/analyte.

82310 — Calcium; total
82330 — Calcium; ionized
82340 — Calcium; urine quantitative, timed specimen
83735 — Magnesium
83970 — Parathormone (parathyroid hormone)
84100 — Phosphorus inorganic (phosphate)
84105 — Phosphorus inorganic (phosphate); urine
Report exact code(s) for each specimen and analyte tested.

Documentation Required

Confirmatory testing recommendations

Confirmatory testing for albuminuria/proteinuria should follow KDIGO guidance: confirm reagent-strip positive results with quantitative laboratory measurements and express as a ratio to urine creatinine; confirm ACR ≥30 mg/g on a random untimed urine with a subsequent first morning void.

If reagent-strip (POCT) indicates albuminuria/proteinuria, obtain quantitative lab measurement and report as ACR or PCR when possible.
Confirm ACR ≥30 mg/g on a random untimed urine with a subsequent first morning midstream urine sample.