P00.4 — Newborn affected by maternal nutritional disorders
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Medical records must document the medical necessity of the serum magnesium test, including the signs, symptoms, and/or diagnosis that prompted the test.
- Laboratories must maintain the physician's order for the serum magnesium test in their records.
- Medical records must contain the serum magnesium lab test results.
- When requesting individual consideration through written redetermination, providers must include all relevant medical records and supporting literature.
Key Coverage Criteria
- ICD-10-CM Codes that Support Medical Necessity — Group 1 (covered diagnoses): D56.1 - Beta thalassemia
- ICD-10-CM Codes that Support Medical Necessity — Group 1 (covered diagnoses): D57.02 - Hb-SS disease with splenic sequestration
- ICD-10-CM Codes that Support Medical Necessity — Group 1 (covered diagnoses): D57.1 - Sickle-cell disease without crisis
- ICD-10-CM Codes that Support Medical Necessity — Group 1 (covered diagnoses): D57.212 - Sickle-cell/Hb-C disease with splenic sequestration
- ICD-10-CM Codes that Support Medical Necessity — Group 1 (covered diagnoses): D57.412 - Sickle-cell thalassemia, unspecified, with splenic sequestration
- ICD-10-CM Codes that Support Medical Necessity — Group 1 (covered diagnoses): D57.812 - Other sickle-cell disorders with splenic sequestration
4 Active Policies
A57198 — Billing and Coding: Serum Magnesium
A57189 — Billing and Coding: Serum Magnesium
L36700 — Serum Magnesium
L36702 — Serum Magnesium
Related Codes
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