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Medicare Coverage Policies
May 2013 update
Dear Client,
This manual was developed to provide a ready reference of coverage policies so you can
determine whether it is necessary to have Medicare patients sign an Advance Beneficiary
Notice (ABN). Use this manual to verify the need for an ABN by checking the ICD-9 code
provided by the physician against the policy for medical necessity. If the ICD-9 code is not listed
(with the exception of the Blood Count policy - see below), have the patient sign an ABN before
drawing the specimen.
There are two types of policies located in this manual. One is the National Coverage Decisions
(NCD) Uniform Lab Policies, and the other is the Local Coverage Decisions (LCDs).
The policy type for each test contained in this manual can be found below and to the right of
the test name:
Alpha-fetoprotein
Policy Type: NCD (National Coverage Decision)
For each policy, you will see its CPT code(s) listed below the heading area and the ICD-9
(diagnosis) codes that are accepted for payment. There is an exception to this format: the list
of covered codes for the Blood Count policy is so expansive that the non-covered codes are
listed instead.
Please note that this policy information is specific to the State of Oregon. The policy is regularly
updated. Visit our website at www.peacehealthlabs.org/publications for the most recent
update and to view or print this manual online.
Medicare regulations state that it is the responsibility of the physician or an authorized
representative to select the diagnosis based on the medical record, not reimbursement
considerations. This manual is not meant to suggest or in any way influence the selection of an
ICD-9 code.
If you have questions about this manual, please call PeaceHealth Laboratories Billing at 541687-2134 or 800-826-3616. For additional copies, call Melissa Sanders at 541-349-8447.
PeaceHealth Laboratories
PeaceHealth Laboratories
PeaceHealth Laboratories
PeaceHealth Laboratories
Medicare Coverage Policies
Universal Policy Guidelines: NCD reasons for denial
For all NCD policies, the following reasons for denial apply:
Note: This section has not been negotiated by the Negotiated Rulemaking Committee. It
includes CMS’s interpretation of its longstanding policies and is included for informational
purposes.
•
Tests for screening purposes that are performed in the absence of signs, symptoms,
complaints, or personal history of disease or injury are not covered except as explicitly
authorized by statute. These include exams required by insurance companies, business
establishments, government agencies, or other third parties.
•
Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or
injury are not covered according to the statute.
•
Failure to provide documentation of the medical necessity of tests may result in denial of
claims. The documentation may include notes documenting relevant signs, symptoms, or
abnormal findings that substantiate the medical necessity for ordering the tests. In addition,
failure to provide independent verification that the test was ordered by the treating
physician (or qualified non-physician practitioner) through documentation in the physician’s
office may result in denial.
•
A claim for a test for which there is a national coverage or local medical review policy will be
denied as not reasonable and necessary if it is submitted without an ICD–9–CM code or
narrative diagnosis listed as covered in the policy unless other medical documentation
justifying the necessity is submitted with the claim.
•
If a national or local policy identifies a frequency expectation, a claim for a test that exceeds
that expectation may be denied as not reasonable and necessary, unless it is submitted with
documentation justifying increased frequency.
•
Tests that are not ordered by a treating physician or other qualified treating nonphysician
practitioner acting within the scope of their license and in compliance with Medicare
requirements will be denied as not reasonable and necessary.
•
Failure of the laboratory performing the test to have the appropriate Clinical Laboratory
Improvement Amendment of 1988 (CLIA) certificate for the testing performed will result in
denial of claims.
PeaceHealth Laboratories
Medicare Coverage Policies
Universal Policy Guidelines: NCD coding guidelines
For all NCD policies, the following coding guidelines should be
observed:
1. Any claim for a clinical diagnostic laboratory service must be submitted with an ICD–9–CM
diagnosis code. Codes that describe symptoms and signs, as opposed to diagnoses, should be
provided for reporting purposes when a diagnosis has not been established by the physician.
(Based on Coding Clinic for ICD–9–CM, Fourth Quarter 1995, page 43).
2. Screening is the testing for disease or disease precursors so that early detection and treatment
can be provided for those who test positive for the disease. Screening tests are performed
when no specific sign, symptom, or diagnosis is present and the patient has not been exposed
to a disease. The testing of a person to rule out or to confirm a suspected diagnosis because the
patient has a sign and/or symptom is a diagnostic test, not a screening. In these cases, the sign
or symptom should be used to explain the reason for the test. When the reason for performing
a test is because the patient has had contact with, or exposure to, a communicable disease, the
appropriate code from category V01, Contact with or exposure to communicable diseases,
should be assigned, not a screening code, but the test may still be considered screening and not
covered by Medicare. For screening tests, the appropriate ICD–9–CM screening code from
categories V28 or V73–V82 (or comparable narrative) should be used. (From Coding Clinic for
ICD–9–CM, Fourth Quarter 1996, pages 50 and 52).
3. A three-digit code is to be used only if it is not further subdivided. Where fourth-digit and/or
fifth-digit sub-classifications are provided, they must be assigned. A code is invalid if it has not
been coded to the full number of digits required for that code. (From Coding Clinic for ICD–9–
CM. Fourth Quarter, 1995, page 44).
4. Diagnoses documented as ‘‘probable,’’ ‘‘suspected,’’ ‘‘questionable,’’ ‘‘rule-out,’’ or ‘‘working
diagnosis’’ should not be coded as though they exist. Rather, code the condition(s) to the
highest degree of certainty for that encounter, such as signs, symptoms, abnormal test results,
exposure to communicable disease or other reasons for the visit. (From Coding Clinic for ICD–9–
CM, Fourth Quarter 1995, page 45).
5. When a non-specific ICD–9 code is submitted, the underlying sign, symptom, or condition must
be related to the indications for the test.
PeaceHealth Laboratories
Medicare Coverage Policies
Universal Policy Guidelines: LCD reasons for denial
For all LCD policies, the following reasons for denial apply:
Medicare does not cover routine screening in the absence of signs or symptoms. Periodic
monitoring of serum levels of high-risk medication is not considered screening.
When the documentation does not meet the criteria for the service rendered or the
documentation does not establish the medical necessity for the services, such services will be
denied as "not reasonable and necessary" under Section 1862 (a) (1) of the Social Security Act.
Medicare Coverage Policies
Universal Policy Guidelines: LCD coding guidelines
For all LCD policies, the following coding guidelines should be observed:
ICD-9-CM code V82.9 (special screening of
other conditions, unspecified condition)
should be used to indicate screening tests
performed. Use of V82.9 will result in the
denial of claims as non-covered screening
services.
All ICD-9-CM diagnosis codes must be
coded to the highest level of specificity.
Reviewing results of laboratory tests,
phoning results to patients, filing such
results, and such activities as obtaining,
reviewing, and analyzing the appropriate
diagnostic tests, etc., are services which are
covered by the program, and payment for
these services is included in the payment
for the evaluation and management (E&M)
services to the patient.
PeaceHealth Laboratories
Medicare Coverage Policies
Table of Contents
Policy Name
Testing Indications and Limitations
Alpha-fetoprotein
B-type Natriuretic Peptide (BNP)
Blood Counts
CA 125
CA 15-3 (27.29)
CA 19-9
Carcinoembryonic Antigen (CEA)
Collagen Cross Links
Cytogenetics
Digoxin
GGT
General Health Panel
Genetic Testing
Glucose
Glycated Protein/Glycohemoglobin
Gonadotropin, Chorionic (hCG)
Hepatitis Panel
HIV testing; Diagnosis
HIV testing; Prognosis, including monitoring
Iron Studies
Lipid Testing
Occult Blood, Fecal
Partial Thromboplastin Time (PTT)
Prostate Specific Antigen (PSA)
Prothrombin Time
Screening for Sexually Transmitted Infections (STI’s)
Thyroid Testing
Urinalysis
Urine Culture, Bacterial/Sensitivity Studies
Vitamin D Assay
Additional Coding Guidelines
PeaceHealth Laboratories
NCD
LCD
N/A
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84-89
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PeaceHealth Laboratories
Medicare Coverage Policies
NCD/LCD Policy Updates
Policy Name
Alpha-fetoprotein
B-type Natriuretic Peptide (BNP)
Blood Counts
CA 125
CA 15-3 (27.29)
CA 19-9
Carcinoembryonic Antigen (CEA)
Collagen Cross Links
Cytogenetics
Digoxin
GGT
General Health Panel
Genetic Testing
Glucose
Glycated Protein/Glycohemoglobin
Gonadotropin, Chorionic (hCG)
Hepatitis Panel
HIV testing; Diagnosis
HIV testing; Prognosis, including monitoring
Iron Studies
Lipid Testing
Occult Blood, Fecal
Partial Thromboplastin Time (PTT)
Prostate Specific Antigen (PSA)
Prothrombin Time
Screening for Sexually Transmitted Infections (STI’s)
Thyroid Testing
NCD
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LCD
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Urinalysis
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Urine Culture, Bacterial/Sensitivity Studies
Vitamin D Assay
1/12
3/12
4/12
10/06
10/06
10/06
10/09
10/04
3/12
10/10
10/11
9/95
12/12
10/11
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1/07
10/11
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1/12
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5/13
10/10
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PeaceHealth Laboratories
Last
update
3/12
PeaceHealth Laboratories
Medicare Coverage Policies
Test/CPT Listing
Policy Name
NCD
Alpha-fetoprotein

B-type Natriuretic Peptide (BNP)

CA 125





CA 15-3 (27.29)
CA 19-9
Carcinoembryonic Antigen (CEA)
Collagen Cross Links
Cytogenetics
General Health Panel
Genetic Testing
Glucose
Glycated Protein/Glycohemoglobin
Gonadotropin, Chorionic (hCG)
Hepatitis Panel




HIV testing; Diagnosis

HIV testing; Prognosis, including monitoring
Iron Studies


Lipid Testing

Occult blood, Diagnostic
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
Prostate Specific Antigen (PSA)
Prothrombin Time
86304
86300
86301
82378
82523


GGT
PeaceHealth Laboratories
83880
85004, 85007, 85008, 85013,
85014, 85018, 85025, 85027,
85032, 85048, 85049

Digoxin
CPT Code(s)
82105

Blood Counts
Partial Thromboplastin Time (PTT)
LCD
88120, 88121, 88230-88299
80162
82977

80050

81201, 81202, 81203, 81211,
81212, 81213, 81214, 81215,
81216, 81217, 81270, 81275,
81292, 81293, 81294, 81295,
81296, 81297, 81298, 81299,
81300, 81317, 81318, 81319,
81381, 81401, 81403, 81405,
81406, and 88363
82947, 82948, 82962
82985, 83036
84702
80074
86689, 86701-86703, 87390,
87391, 87534, 87535, 87537,
87538
87536, 87539
82728, 83540, 83550, 84466
80061, 82465, 83700, 83701,
83704, 83718, 83721, 84478
82272
85730
84153
85610
Medicare Coverage Policies (con’t)
Test/CPT Listing
Policy Name
NCD
LCD
Screening for Sexually Transmitted Infections
(STI’s)

Thyroid Testing

Urinalysis

Urine Culture, Bacterial/Sensitivity Studies

Vitamin D Assay
87086, 87088, 87184, 87186

PeaceHealth Laboratories
CPT Code(s)
Chlamydia (86631, 86632,
87110, 87270, 87320, 87490,
87491, 87810) (*87800 used
for combined Chlamydia &
Gonorrhea testing)
Gonorrhea (87590, 87591,
87850, 87800*) Syphilis
(86592, 86593, 86780) and
Hepatitis B (Hepatitis B
surface antigen) (87340,
87341)
84436, 84439, 84443, 84479
81000, 81001, 81002, 81003,
81005, 81007, 81015, 81020
82306, 82652
Indications and Limitations
Test Name
Indications/Limitations
Alpha-fetoprotein
Policy 190.25
AFP is useful for the diagnosis of hepatocellular carcinoma in highrisk patients (such as alcoholic cirrhosis, cirrhosis of viral etiology,
hemochromatosis, and alpha 1-antitrypsin deficiency) and in
separating patients with benign hepatocellular neoplasms or
metastases from those with hepatocellular carcinoma and, as a nonspecific tumor associated antigen, serves in marking germ cell
neoplasms of the testis, ovary, retro peritoneum, and mediastinum.
B-type Natriuretic Peptide
Policy L31568
Indications
BNP measurements may be considered reasonable and necessary
when used in combination with other medical data such as medical
history, physical examination, laboratory studies, chest x-ray, and
electrocardiography in the following two clinical situations.
•
Acute exacerbation of dyspnea in patients with known or
suspected pulmonary or other non-cardiac causes of
dyspnea to rule out CHF. Plasma BNP levels are significantly
increased in patients with CHF presenting with acute
dyspnea compared to patients presenting with acute
dyspnea due to other causes.
•
Acute exacerbation of dyspnea in patients known to suffer
from both chronic obstructive pulmonary disease (COPD)
and CHF. The BNP level may assist the physician distinguish
between an exacerbation of COPD and decompensated CHF.
Plasma BNP levels are significantly increased in patients with
CHF with or without concurrent lung disease compared with
patients who have primary lung disease.
Limitations
BNP measurements must be assessed in conjunction with standard
diagnostic tests, medical history and clinical findings. The efficacy of
BNP measurement as a stand-alone test has not been established
yet. Moreover, certain conditions such as (and not limited to)
ischemia, infarction and renal insufficiency, advanced age, female
gender may cause elevation of circulating BNP; obesity, upstream
heart failure and other conditions lower the BNP level. These
conditions confound the interpretation of BNP levels to varying
extents.
The efficacy and/or utility of plasma BNP level as a monitor of the
degree of CHF or the efficiency of CHF treatment has not been
established. Treatment guided by BNP has not been shown to be
PeaceHealth Laboratories | Indications and Limitations
i
Indications and Limitations
Test Name
Indications/Limitations
B-type Natriuretic Peptide
Policy L31568
superior to symptom-guided treatment in either clinical or quality of
life outcomes. Therefore, BNP measurements for monitoring and
management of CHF are non-covered.
The efficacy but not the utility of BNP as a risk stratification tool (to
assess risk of death, myocardial infarction or congestive heart
failure) among patients with acute coronary syndrome (myocardial
infarction with or without T-wave elevation and unstable angina) has
been established. However, the assessment of BNP level has not
been shown to alter patient management. The BNP is not
sufficiently sensitive to either preclude or necessitate any other
evaluation or treatment in this group of patients.
Screening examinations are statutorily non-covered.
PeaceHealth Laboratories | Indications and Limitations
ii
Indications and Limitations
Test Name
Indications/Limitations
Blood Counts
Policy 190.15
Indications
Indications for a CBC or hemogram include red cell, platelet, and
white cell disorders. Examples are enumerated individually below.
1. Indications for a CBC generally include the evaluation of bone
marrow dysfunction as a result of neoplasms, therapeutic
agents, exposure to toxic substances, or pregnancy. The CBC is
also useful in assessing peripheral destruction of blood cells,
suspected bone marrow failure or bone marrow infiltrate,
suspected myeloproliferative, myelodysplastic, or
lymphoproliferative processes, and immune disorders.
2. Indications for hemogram or CBC related to red cell (RBC)
parameters of the hemogram include signs, symptoms, test
results, illness, or disease that can be associated with anemia or
other red blood cell disorder (e.g., pallor, weakness, fatigue,
weight loss, bleeding, acute injury associated with blood loss or
suspected blood loss, abnormal menstrual bleeding, hematuria,
hematemesis, hematochezia, positive fecal occult blood test,
malnutrition, vitamin deficiency, malabsorption, neuropathy,
known malignancy, presence of acute or chronic disease that
may have associated anemia, coagulation or hemostatic
disorders, postural dizziness, syncope, abdominal pain, change
in bowel habits, chronic marrow hypoplasia or decreased RBC
production, tachycardia, systolic heart murmur, congestive heart
failure, dyspnea, angina, nailbed deformities, growth
retardation, jaundice, hepatomegaly, splenomegaly,
lymphadenopathy, ulcers on the lower extremities).
3. Indications for hemogram or CBC related to red cell (RBC)
parameters of the hemogram include signs, symptoms, test
results, illness, or disease that can be associated with
polycythemia (for example, fever, chills, ruddy skin, conjunctival
redness, cough, wheezing, cyanosis, clubbing of the fingers,
orthopnea, heart murmur, headache, vague cognitive changes
including memory changes, sleep apnea, weakness, pruritus,
dizziness, excessive sweating, visual symptoms, weight loss,
massive obesity, gastrointestinal bleeding, paresthesias,
dyspnea, joint symptoms, epigastric distress, pain and erythema
of the fingers or toes, venous or arterial thrombosis,
thromboembolism, myocardial infarction, stroke, transient
ischemic attacks, congenital heart disease, chronic obstructive
pulmonary disease, increased erythropoietin production
associated with neoplastic, renal or hepatic disorders, androgen
or diuretic use, splenomegaly, hepatomegaly, diastolic
hypertension.)
PeaceHealth Laboratories | Indications and Limitations
iii
Indications and Limitations
Test Name
Blood Counts
Policy 190.15
Indications/Limitations
4. Specific indications for CBC with differential count related to the
WBC include signs, symptoms, test results, illness, or disease
associated with leukemia, infections or inflammatory processes,
suspected bone marrow failure or bone marrow infiltrate,
suspected myeloproliferative, myelodysplastic or
lymphoproliferative disorder, use of drugs that may cause
leukopenia, and immune disorders (e.g., fever, chills, sweats,
shock, fatigue, malaise, tachycardia, tachypnea, heart murmur,
seizures, alterations of consciousness, meningismus, pain such
as headache, abdominal pain, arthralgia, odynophagia, or
dysuria, redness or swelling of skin, soft tissue bone, or joint,
ulcers of the skin or mucous membranes, gangrene, mucous
membrane discharge, bleeding, thrombosis, respiratory failure,
pulmonary infiltrate, jaundice, diarrhea, vomiting,
hepatomegaly, splenomegaly, lymphadenopathy, opportunistic
infection such as oral candidiasis.)
5. Specific indications for CBC related to the platelet count include
signs, symptoms, test results, illness, or disease associated with
increased or decreased platelet production and destruction, or
platelet dysfunction(e.g., gastrointestinal bleeding,
genitourinary tract bleeding, bilateral epistaxis, thrombosis,
ecchymosis, purpura, jaundice, petechiae, fever, heparin
therapy, suspected DIC, shock, pre-eclampsia, neonate with
maternal ITP, massive transfusion, recent platelet transfusion,
cardiopulmonary bypass, hemolytic uremic syndrome, renal
diseases, lymphadenopathy, hepatomegaly, splenomegaly,
hypersplenism, neurologic abnormalities, viral or other
infection, myeloproliferative, myelodysplastic, or
lymphoproliferative disorder, thrombosis, exposure to toxic
agents, excessive alcohol ingestion, autoimmune disorders (SLE,
RA and other).
6. Indications for hemogram or CBC related to red cell (RBC)
parameters of the hemogram include, in addition to those
already listed, thalassemia, suspected hemoglobinopathy, lead
poisoning, arsenic poisoning, and spherocytosis.
7. Specific indications for CBC with differential count related to the
WBC include, in addition to those already listed, storage
diseases/mucopolysaccharidoses, and use of drugs that cause
leukocytosis such as G-CSF or GM-CSF.
8. Specific indications for CBC related to platelet count include, in
addition to those already listed, May-Hegglin syndrome and
Wiskott-Aldrich syndrome.
PeaceHealth Laboratories | Indications and Limitations
iv
Indications and Limitations
Test Name
Indications/Limitations
Blood Counts
Policy 190.15
Limitations
1. Testing of patients who are asymptomatic, or who do not have a
condition that could be expected to result in a hematological
abnormality, is screening and is not a covered service.
2. In some circumstances it may be appropriate to perform only a
hemoglobin or hematocrit to assess the oxygen carrying capacity
of the blood. When the ordering provider requests only a
hemoglobin or hematocrit, the remaining components of the
CBC are not covered.
3. When a blood count is performed for an end-stage renal disease
(ESRD) patient, and is billed outside the ESRD rate,
documentation of the medical necessity for the blood count
must be submitted with the claim.
4. In some patients presenting with certain signs, symptoms or
diseases, a single CBC may be appropriate. Repeat testing may
not be indicated unless abnormal results are found, or unless
there is a change in clinical condition. If repeat testing is
performed, a more descriptive diagnosis code (e.g., anemia)
should be reported to support medical necessity. However,
repeat testing may be indicated where results are normal in
patients with conditions where there is a continued risk for the
development of hematologic abnormality.
CA 125
Policy 190.28
Indications
CA 125 is a high molecular weight serum tumor marker elevated in
80% of patients who present with epithelial ovarian carcinoma. It is
also elevated in carcinomas of the fallopian tube, endometrium, and
endocervix. An elevated level may also be associated with the
presence of a malignant mesothelioma or primary peritoneal
carcinoma.
A CA125 level may be obtained as part of the initial pre-operative
work-up for women presenting with a suspicious pelvic mass to be
used as a baseline for purposes of post-operative monitoring. Initial
declines in CA 125 after initial surgery and/or chemotherapy for
PeaceHealth Laboratories | Indications and Limitations
v
Indications and Limitations
Test Name
Indications/Limitations
CA 125
Policy 190.28
ovarian carcinoma are also measured by obtaining three serum
levels during the first month post treatment to determine the
patient's CA 125 half-life, which has significant prognostic
implications.
The CA 125 levels are again obtained at the completion of
chemotherapy as an index of residual disease. Surveillance CA125
measurements are generally obtained every 3 months for 2 years,
every 6 months for the next 3 years, and yearly thereafter. CA 125
levels are also an important indicator of a patient's response to
therapy in the presence of advanced or recurrent disease. In this
setting, CA 125 levels may be obtained prior to each treatment
cycle.
Limitations
These services are not covered for the evaluation of patients with
signs or symptoms suggestive of malignancy. The service may be
ordered at times necessary to assess either the presence of
recurrent disease or the patient's response to treatment with
subsequent treatment cycles.
The CA 125 is specifically not covered for aiding in the differential
diagnosis of patients with a pelvic mass as the sensitivity and
specificity of the test is not sufficient. In general, a single "tumor
marker" will suffice in following a patient with one of these
malignancies.
CA 15-3 (27.29)
Policy 190.29
Indications
Multiple tumor markers are available for monitoring the response of
certain malignancies to therapy and assessing whether residual
tumor exists’ post-surgical therapy.
CA 15-3 is often medically necessary to aid in the management of
patients with breast cancer. Serial testing must be used in
conjunction with other clinical methods for monitoring breast
cancer. For monitoring, if medically necessary, use consistently
either CA 15-3 or CA 27.29, not both.
CA 27.29 is equivalent to CA 15-3 in its usage in management of
patients with breast cancer.
Limitations
These services are not covered for the evaluation of patients with
signs or symptoms suggestive of malignancy. The service may be
ordered at times necessary to assess either the presence of
recurrent disease or the patient's response to treatment with
subsequent treatment cycles.
PeaceHealth Laboratories | Indications and Limitations
vi
Indications and Limitations
Test Name
Indications/Limitations
CA 19-9
Policy 190.30
Indications
Multiple tumor markers are available for monitoring the response of
certain malignancies to therapy and assessing whether residual
tumor exists’ post-surgical therapy.
Levels are useful in following the course of patients with established
diagnosis of pancreatic and biliary ductal carcinoma. The test is not
indicated for diagnosing these two diseases.
Limitations
These services are not covered for the evaluation of patients with
signs or symptoms suggestive of malignancy. The service may be
ordered at times necessary to assess either the presence of
recurrent disease or the patient's response to treatment with
subsequent treatment cycles.
Carcinoembryonic Antigen
(CEA)
Policy 190.26
Indications
CEA may be medically necessary for follow-up of patients with
colorectal carcinoma. It would however only be medically necessary
at treatment decision making points. In some clinical situations (e.g.
adenocarcinoma of the lung, small cell carcinoma of the lung, and
some gastrointestinal carcinomas) when a more specific marker is
not expressed by the tumor, CEA may be a medically necessary
alternative marker for monitoring. Preoperative CEA may also be
helpful in determining the post-operative adequacy of surgical
resection and subsequent medical management. In general, a single
tumor marker will suffice in following patients with colorectal
carcinoma or other malignancies that express such tumor markers.
In following patients who have had treatment for colorectal
carcinoma, ASCO guideline suggests that if resection of liver
metastasis would be indicated, it is recommended that postoperative CEA testing be performed every two to three months in
patients with initial stage II or stage III disease for at least two years
after diagnosis.
For patients with metastatic solid tumors which express CEA, CEA
may be measured at the start of the treatment and with subsequent
treatment cycles to assess the tumor's response to therapy.
Limitations
Serum CEA determinations are generally not indicated more
frequently than once per chemotherapy treatment cycle for patients
with metastatic solid tumors which express CEA or every two
months post-surgical treatment for patients who have had
colorectal carcinoma. However, it may be proper to order the test
PeaceHealth Laboratories | Indications and Limitations
vii
Indications and Limitations
Test Name
Indications/Limitations
Carcinoembryonic
Antigen (CEA)
Policy 190.26
more frequently in certain situations, for example, when there has
been a significant change from prior CEA level or a significant change
in patient status which could reflect disease progression or
recurrence.
Testing with a diagnosis of an in situ carcinoma is not reasonably
done more frequently than once, unless the result is abnormal, in
which case the test may be repeated once.
Collagen Cross Links
Policy 190.19
Indications
Generally speaking, collagen crosslink testing is useful mostly in "fast
losers" of bone. The age when these bone markers can help direct
therapy is often pre-Medicare. By the time a fast loser of bone
reaches age 65, she will most likely have been stabilized by
appropriate therapy or have lost so much bone mass that further
testing is useless. Coverage for bone marker assays may be
established, however, for younger Medicare beneficiaries and for
those men and women who might become fast losers because of
some other therapy such as glucocorticoids. Safeguards should be
incorporated to prevent excessive use of tests in patients for whom
they have no clinical relevance.
Collagen crosslinks testing is used to:
1. Identify individuals with elevated bone resorption, who have
osteoporosis in whom response to treatment is being
monitored;
2. Predict response (as assessed by bone mass measurements) to
FDA approved antiresorptive therapy in postmenopausal
women; and
3. Assess response to treatment of patients with osteoporosis,
Paget's disease of the bone, or risk for osteoporosis where
treatment may include FDA approved antiresorptive agents,
anti-estrogens or selective estrogen receptor moderators.
Limitations
Because of significant specimen to specimen collagen crosslink
physiologic variability (15-20%), current recommendations for
appropriate utilization include: one or two base-line assays from
specified urine collections on separate days; followed by a repeat
assay about three months after starting anti-resorptive therapy;
followed by a repeat assay in 12 months after the three-month
assay; and thereafter not more than annually, unless there is a
change in therapy in which circumstance an additional test may be
indicated three months after the initiation of new therapy.
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Indications and Limitations
Test Name
Indications/Limitations
Cytogenetics
Cytogenetics
Policy
PolicyL23846
L24295
Cytogenetics is the study of chromosomes by light or fluorescent
microscopy. Cytogenetic testing is used to study an individual’s
chromosome makeup. The term karyotyping refers to the
arrangement of nucleus chromosomes in order from the largest to
the smallest to analyze their number and structure. Cytogenetic
testing involves the determination of chromosome number and
structure; variations in either can produce numerous physical
abnormalities. With cytogenetic testing, the total chromosome
count is determined first, followed by the sex chromosome
complement and then by any abnormalities. A normal karyotype of
chromosomes consists of a pattern of 22 pairs of autosomal
chromosomes and a pair of sex chromosomes: XY for the male and
XX for the female. A plus (+) or minus (-) sign indicates, respectively,
a gain or loss of chromosomal material.
Specimens for cytogenetic analysis can be obtained for routine
analysis from the peripheral blood, in which case T lymphocytes are
examined; from amniotic fluid for culture of amniocytes; from
trophoblastic cells from the chorionic villus; from bone marrow;
from solid tumors, and from cultured fibroblasts, usually obtained
from a skin biopsy. Enough cells must be examined so that the
chance of missing a cytogenetically distinct cell line (a situation of
mosaicism) is statistically low. For most clinical indications, 20
mitoses are examined and counted under direct microscopic
visualization, and two are photographed or digitalized and
karyotypes are prepared. Observation of aberrations usually
prompts more extended scrutiny, and in many cases, further analysis
of the original culture.
Per Medicare National Coverage Determinations (NCD) Manual, 1003, Section 190.3:
“Medicare covers these tests when they are reasonable and
necessary for the diagnosis or treatment of the following conditions:
● Genetic disorders (e.g., mongolism) in a fetus; (See the Medicare
Benefit Policy Chapter 15, "Covered Medical and Other Health
Services," 20.1)
● Failure of sexual development; or
● Chronic myelogenous leukemia.
● Acute leukemias, lymphoid (FAB L1-L3), myeloid (FAB M0-M7) and
unclassified; or
● Myelodysplasia.” (End of Quote)
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Indications and Limitations
Test Name
Indications/Limitations
Cytogenetics
Policy L24295
The above quotation obligates the carrier to cover the listed
diagnoses but does not limit coverage to that list. Further, genetic
disorders and failure of sexual development involve chromosomal
abnormalities that are stable over time, and, accordingly, payment
for cytogenetic studies for these abnormalities will be allowed once
per lifetime. This is in contrast to the malignancies, where repeated
cytogenetic studies may be appropriate. At the present time, it
should be noted that, even in cases of genetic disorders, the general
policy limitation is for once per lifetime testing. When clinicallyrelevant technological advances (such as with FISH testing), are
available, and repeat testing is believed to be medically reasonable
and necessary, such claims must be billed using an additional ICD-9CM code. (See the section titled ICD-9-CM Codes that Support
Medical Necessity and attached Coding Guidelines for additional
information.)
Since “Urovysion”, a proprietary test for recurrent bladder cancer
identification and monitoring, utilizes multiple probes, which are
applied simultaneously, for dates of service on and after
01/01/2011, is correctly identified by two new CPT codes included in
this LCD.
NAS finds little evidence in the literature that consistent
chromosomal abnormalities in the conditions of polycythemia vera,
agnogenic myeloid metaplasia, idiopathic thrombocythemia and
multiple myeloma are known, or that their identification is likely to
affect patient care; consequently, these are considered to be
payable diagnoses only when the medical record contains clear,
unequivocal documentation that this testing is medically reasonable
and necessary for the individual case under consideration.
Concerning the testing of HER-2/neu antibodies, Noridian believes
that current literature amply supports the notion that HER-2/neu
tests on histological sections of breast cancers may, in the
appropriate clinical settings, provide useful prognostic information
and therapeutic indications for treating metastatic disease with antiHER-2/neu antibodies. For this or any other medically necessary use
of in situ hybridization (FISH) testing, for dates of service on or after
January 1, 2005, quantitative or semi-quantitative in situ
hybridization (tissue or cellular) performed by computer-assisted
technology should be reported as CPT code 88367 when performed
by a physician (limited to M.D./D.O.). Beginning January 1, 2005,
quantitative or semi-quantitative in situ hybridization (tissue or
cellular) performed by manual methods should be reported as CPT
code 88368 when performed by a physician (limited to M.D./D.O.).
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Indications and Limitations
Test Name
Indications/Limitations
Cytogenetics
Policy L24295
Do not report CPT code 88365 with CPT codes 88367 or 88368 for
the same probe. Only one unit of service may be reported for CPT
code 88365, 88367 or 88368 for each reportable probe. These codes
include both a professional component and a technical component.
When a test for HER-2/neu protein over expression is performed
using an immunocytochemistry technique, the test should be billed
as 88342, immunocytochemistry. Thus, other CPT codes listed in the
CPT/HCPCS Codes section of this policy should not be used when
billing for HER-2/neu antibodies.
Since there is no current provider category for PhD Geneticists,
notwithstanding the certainty that such providers are capable of
demonstrating superb training and expertise, Medicare Contractors
do not have the authority to create a provider category to allow
payment for their services. We encourage these providers to
continue discussion with CMS in this regard.
NAS recognizes that Cytogenetic Testing is an emerging technology
with rapidly expanding indications and will accept recommendations
to reconsider the list of covered diagnoses. However, these requests
for reconsideration must be submitted as a formal reconsideration
(See www.noridianmedicare.com for the reconsideration process.)
and must be accompanied by complete copies of relevant peerreviewed literature that support the recommendation.
Compliance with the provisions in this policy is subject to monitoring
by post payment data analysis and subsequent medical review.
Digoxin
Policy 190.24
Indications
Digoxin levels may be performed to monitor drug levels of
individuals receiving digoxin therapy because the margin of safety
between side effects and toxicity is narrow or because the blood
level may not be high enough to achieve the desired clinical effect.
Clinical indications may include individuals on digoxin:
•
•
•
•
•
•
With symptoms, signs or electrocardiogram (ECG) suggestive of
digoxin toxicity.
Taking medications that influence absorption, bioavailability,
distribution, and/or elimination of digoxin.
With impaired renal, hepatic, gastrointestinal, or thyroid
function.
With pH and/or electrolyte abnormalities.
With unstable cardiovascular status, including myocarditis.
Requiring monitoring of patient compliance.
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Indications and Limitations
Test Name
Indications/Limitations
Digoxin
Policy 190.24
Clinical indications may include individuals:
• Suspected of accidental or intended overdose.
• Who have an acceptable cardiac diagnosis (as listed) and for
whom an accurate history of use of digoxin is unobtainable.
The value of obtaining regular serum digoxin levels is uncertain, but
it may be reasonable to check levels once yearly after a steady state
is achieved. In addition, it may be reasonable to check the level if:
• Heart failure status worsens.
• Renal function deteriorates.
• Additional medications are added that could affect the digoxin
level.
• Signs or symptoms of toxicity develop.
Steady state will be reached in approximately 1 week in patients
with normal renal function, although 2?3 weeks may be needed in
patients with renal impairment. After changes in dosages or the
addition of a medication that could affect the digoxin level, it is
reasonable to check the digoxin level one week after the change or
addition. Based on the clinical situation, in cases of digoxin toxicity,
testing may need to be done more than once a week.
Digoxin is indicated for the treatment of patients with heart failure
due to systolic dysfunction and for reduction of the ventricular
response in patients with atrial fibrillation or flutter. Digoxin may
also be indicated for the treatment of other supraventricular
arrhythmias, particularly in the presence of heart failure.
Limitations
This test is not appropriate for patients on digitoxin or treated with
digoxin FAB (fragment antigen binding) antibody.
Gamma Glutamyl Transferase
(GGT)
Policy 190.32
Indications
1. To provide information about known or suspected hepatobiliary
disease, for example:
a. Following chronic alcohol or drug ingestion.
b. Following exposure to hepatotoxins.
c. When using medication known to have a potential for
causing liver toxicity (e.g., following the drug
manufacturer's recommendations).
d. Following infection (e.g., viral hepatitis and other
specific infections such as amoebiasis, tuberculosis,
psittacosis, and similar infections).
2. To assess liver injury/function following diagnosis of primary or
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Indications and Limitations
Test Name
Indications/Limitations
Gamma Glutamyl Transferase
(GGT)
Policy 190.32
secondary malignant neoplasms.
3. To assess liver injury/function in a wide variety of disorders and
diseases known to cause liver involvement (e.g., diabetes
mellitus, malnutrition, disorders of iron and mineral metabolism,
sarcoidosis, amyloidosis, lupus, and hypertension).
4. To assess liver function related to gastrointestinal disease.
5. To assess liver function related to pancreatic disease.
6. To assess liver function in patients subsequent to liver
transplantation.
7. To differentiate between the different sources of elevated
alkaline phosphatase activity.
Limitations
When used to assess liver dysfunction secondary to existing nonhepatobiliary disease with no change in signs, symptoms, or
treatment, it is generally not necessary to repeat a GGT
determination after a normal result has been obtained unless new
indications are present.
If the GGT is the only "liver" enzyme abnormally high, it is generally
not necessary to pursue further evaluation for liver disease for this
specific indication.
When used to determine if other abnormal enzyme tests reflect liver
abnormality rather than other tissue, it generally is not necessary to
repeat a GGT more than one time per week.
Because of the extreme sensitivity of GGT as a marker for
cytochrome oxidase induction or cell membrane permeability, it is
generally not useful in monitoring patients with known liver disease.
Genetic Testing
Policy L24308
Screening services, such as pre-symptomatic genetic tests and
services, are those used to detect an undiagnosed disease or disease
predisposition, and as such are not a Medicare benefit and not
covered by Medicare. Similarly, Medicare may not reimburse the
costs of tests/examinations that assess the risk for and/or of a
condition unless the risk assessment clearly and directly effects the
management of the patient. However, Medicare does cover a broad
range of legislatively mandated preventive services to prevent
disease, detect disease early when it is most treatable and curable,
and manage disease so that complications can be avoided. These
services can be found on the CMS website at:
http://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/index.html
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Indications and Limitations
Test Name
Indications/Limitations
Genetic Testing
Policy L24308
Any preventive services and tests not listed on the CMS Preventive
Services webpage are considered non-covered screening
(preventive) tests or services which are not a benefit of the Medicare
program.
Glucose
Policy 190.20
Indications
Blood glucose values are often necessary for the management of
patients with diabetes mellitus, where hyperglycemia and
hypoglycemia are often present. They are also critical in the
determination of control of blood glucose levels in the patient with
impaired fasting glucose (FPG 110-125 mg/dL), the patient with
insulin resistance syndrome and/or carbohydrate intolerance
(excessive rise in glucose following ingestion of glucose or glucose
sources of food), in the patient with a hypoglycemia disorder such as
nesidioblastosis or insulinoma, and in patients with a catabolic or
malnutrition state. In addition to those conditions already listed,
glucose testing may be medically necessary in patients with
tuberculosis, unexplained chronic or recurrent infections,
alcoholism, coronary artery disease (especially in women), or
unexplained skin conditions (including pruritis, local skin infections,
ulceration and gangrene without an established cause).
Many medical conditions may be a consequence of a sustained
elevated or depressed glucose level. These include comas, seizures
or epilepsy, confusion, abnormal hunger, abnormal weight loss or
gain, and loss of sensation. Evaluation of glucose may also be
indicated in patients on medications known to affect carbohydrate
metabolism.
Effective January 1, 2005, the Medicare law expanded coverage to
diabetic screening services. Some forms of blood glucose testing
covered under this national coverage determination may be covered
for screening purposes subject to specified frequencies. See 42 CFR
410.18 and section 90, chapter 18, of the Claims Processing Manual,
for a full description of this screening benefit.
Limitations
Frequent home blood glucose testing by diabetic patients should be
encouraged. In stable, non-hospitalized patients who are unable or
unwilling to do home monitoring, it may be reasonable and
necessary to measure quantitative blood glucose up to four times
annually.
Depending upon the age of the patient, type of diabetes, degree of
control, complications of diabetes, and other co-morbid conditions,
more frequent testing than four times annually may be reasonable
and necessary.
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Indications and Limitations
Test Name
Indications/Limitations
Glucose
Policy 190.20
In some patients presenting with nonspecific signs, symptoms, or
diseases not normally associated with disturbances in glucose
metabolism, a single blood glucose test may be medically necessary.
Repeat testing may not be indicated unless abnormal results are
found or unless there is a change in clinical condition. If repeat
testing is performed, a specific diagnosis code (e.g., diabetes) should
be reported to support medical necessity. However, repeat testing
may be indicated where results are normal in patients with
conditions where there is a confirmed continuing risk of glucose
metabolism abnormality (e.g., monitoring glucocorticoid therapy).
Glycated Protein/
Glycohemoglobin
Policy 190.21
Indications
Glycated hemoglobin/protein testing is widely accepted as medically
necessary for the management and control of diabetes. It is also
valuable to assess hyperglycemia, a history of hyperglycemia or
dangerous hypoglycemia. Glycated protein testing may be used in
place of glycated hemoglobin in the management of diabetic
patients, and is particularly useful in patients who have
abnormalities of erythrocytes such as hemolytic anemia or
hemoglobinopathies.
Limitations
It is not considered reasonable and necessary to perform glycated
hemoglobin tests more often than every three months on a
controlled diabetic patient to determine whether the patient's
metabolic control has been on average within the target range. It is
not considered reasonable and necessary for these tests to be
performed more frequently than once a month for diabetic pregnant
women. Testing for uncontrolled type one or two diabetes mellitus
may require testing more than four times a year. The above
Description Section provides the clinical basis for those situations in
which testing more frequently than four times per annum is
indicated, and medical necessity documentation must support such
testing in excess of the above guidelines.
Many methods for the analysis of glycated hemoglobin show
significant interference from elevated levels of fetal hemoglobin or
by variant hemoglobin molecules. When the glycated hemoglobin
assay is initially performed in these patients, the laboratory may
inform the ordering physician of a possible analytical interference.
Alternative testing, including glycated protein, for example,
fructosamine, may be indicated for the monitoring of the degree of
glycemic control in this situation. It is therefore conceivable that a
patient will have both a glycated hemoglobin and glycated protein
ordered on the same day. This should be limited to the initial assay
of glycated hemoglobin, with subsequent exclusive use of glycated
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Indications and Limitations
Test Name
Indications/Limitations
Glycated Protein/
Glycohemoglobin
Policy 190.21
protein. These tests are not considered to be medically necessary for
the diagnosis of diabetes.
Gonadotropin, Chorionic (hCG)
Policy 190.27
Indications
hCG is useful for monitoring and diagnosis of germ cell neoplasms of
the ovary, testis, mediastinum, retroperitoneum, and central
nervous system. In addition, hCG is useful for monitoring pregnant
patients with vaginal bleeding, hypertension and/or suspected fetal
loss.
Limitations
It is not reasonable and necessary to perform hCG testing more than
once per month for diagnostic purposes. It may be performed
as needed for monitoring of patient progress and treatment.
Qualitative hCG assays are not appropriate for medically managing
patients with known or suspected germ cell neoplasms.
Hepatitis Panel
Policy 190.33
Indications
1. To detect viral hepatitis infection when there are abnormal liver
function test results, with or without signs or symptoms of
hepatitis.
2. Prior to and subsequent to liver transplantation.
Limitations
After a hepatitis diagnosis has been established, only individual
tests, rather than the entire panel, are needed.
HIV Testing; Diagnosis
Policy 190.14
Indications
Diagnostic testing to establish HIV infection may be indicated when
there is a strong clinical suspicion supported by one or more of the
following clinical findings:
1. The patient has a documented, otherwise unexplained, AIDSdefining or AIDS-associated opportunistic infection.
2. The patient has another documented sexually transmitted
disease which identifies significant risk of exposure to HIV and
the potential for an early or subclinical infection.
3. The patient has documented acute or chronic hepatitis B or C
infection that identifies a significant risk of exposure to HIV and
the potential for an early or subclinical infection.
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Indications and Limitations
Test Name
Indications/Limitations
HIV Testing; Diagnosis
Policy 190.14
4. The patient has a documented AIDS-defining or AIDS-associated
neoplasm.
5. The patient has a documented AIDS-associated neurologic
disorder or otherwise unexplained dementia.
6. The patient has another documented AIDS-defining clinical
condition, or a history of other severe, recurrent, or persistent
conditions which suggest an underlying immune deficiency (for
example, cutaneous or mucosal disorders).
7. The patient has otherwise unexplained generalized signs and
symptoms suggestive of a chronic process with an underlying
immune deficiency (for example, fever, weight loss, malaise,
fatigue, chronic diarrhea, failure to thrive, chronic cough,
hemoptysis, shortness of breath, or lymphadenopathy).
8. The patient has otherwise unexplained laboratory evidence of a
chronic disease process with an underlying immune deficiency
(for example, anemia, leukopenia, pancytopenia, lymphopenia,
or low CD4+ lymphocyte count).
9. The patient has signs and symptoms of acute retroviral
syndrome with fever, malaise, lymphadenopathy, and skin rash.
10. The patient has documented exposure to blood or body fluids
known to be capable of transmitting HIV (for example,
needlesticks and other significant blood exposures) and antiviral
therapy is initiated or anticipated to be initiated.
11. The patient is undergoing treatment for rape. (HIV testing is a
part of the rape treatment protocol.)
Limitations
1. HIV antibody testing in the United States is usually performed
using HIV-1 or HIV-½ combination tests. HIV-2 testing is
indicated if clinical circumstances suggest HIV-2 is likely (that is,
compatible clinical findings and HIV-1 test negative). HIV-2
testing may also be indicated in areas of the country where
there is greater prevalence of HIV-2 infections.
2. The Western Blot test should be performed only after
documentation that the initial EIA tests are repeatedly positive
or equivocal on a single sample.
3. The HIV antigen tests currently have no defined diagnostic
usage.
4. Direct viral RNA detection may be performed in those situations
where serologic
testing does not establish a diagnosis but strong clinical
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Indications and Limitations
Test Name
Indications/Limitations
HIV Testing; Diagnosis
Policy 190.14
suspicion persists (for example, acute retroviral syndrome,
nonspecific serologic evidence of HIV, or perinatal HIV infection).
5. If initial serologic tests confirm an HIV infection, repeat testing is
not indicated.
6. If initial serologic tests are HIV EIA negative and there is no
indication for confirmation of infection by viral RNA detection,
the interval prior to retesting is 3-6 months.
7. Testing for evidence of HIV infection using serologic methods
may be medically appropriate in situations where there is a risk
of exposure to HIV. However, in the absence of a documented
AIDS defining or HIV- associated disease, an HIV associated sign
or symptom, or documented exposure to a known HIV-infected
source, the testing is considered by Medicare to be screening
and thus is not covered by Medicare (for example, history of
multiple blood component transfusions, exposure to blood or
body fluids not resulting in consideration of therapy, history of
transplant, history of illicit drug use, multiple sexual partners,
same-sex encounters, prostitution, or contact with prostitutes).
8. The CPT Editorial Panel has issued a number of codes for
infectious agent detection by direct antigen or nucleic acid probe
techniques that have not yet been developed or are only being
used on an investigational basis. Laboratory providers are
advised to remain current on FDA-approval status for these
tests.
HIV Testing; Prognosis
Policy 190.13
Indications
1. A plasma HIV RNA baseline level may be medically necessary in
any patient with confirmed HIV infection.
2. Regular periodic measurement of plasma HIV RNA levels may be
medically necessary to determine risk for disease progression in
an HIV-infected individual and to determine when to initiate or
modify antiretroviral treatment regimens.
3. In clinical situations where the risk of HIV infection is significant
and initiation of therapy is anticipated, a baseline HIV
quantification may be performed. These situations include:
a. Persistence of borderline or equivocal serologic
reactivity in an at-risk individual.
b. Signs and symptoms of acute retroviral syndrome
characterized by fever, malaise, lymphadenopathy and
rash in an at-risk individual.
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Indications and Limitations
Test Name
Indications/Limitations
HIV Testing; Prognosis
Policy 190.13
Limitations
1. Viral quantification may be appropriate for prognostic use
including baseline determination, periodic monitoring, and
monitoring of response to therapy. Use as a diagnostic test
method is not indicated.
2. Measurement of plasma HIV RNA levels should be performed at
the time of establishment of an HIV infection diagnosis. For an
accurate baseline, 2 specimens in a 2-week period are
appropriate.
3. For prognosis including anti-retroviral therapy monitoring,
regular, periodic measurements are appropriate. The frequency
of viral load testing should be consistent with the most current
Centers for Disease Control and Prevention guidelines for use of
anti-retroviral agents in adults and adolescents or pediatrics.
4. Because differences in absolute HIV copy number are known to
occur using different assays, plasma HIV RNA levels should be
measured by the same analytical method. A change in assay
method may necessitate re-establishment of a baseline.
5. Nucleic acid quantification techniques are representative of
rapidly emerging and evolving new technologies. As such, users
are advised to remain current on FDA-approval status.
Iron Studies
Policy 190.18
Indications
1. Ferritin, iron and either iron binding capacity or transferrin are
useful in the differential diagnosis of iron deficiency, anemia,
and for iron overload conditions.
a. The following presentations are examples that may
support the use of these studies for evaluating iron
deficiency: certain abnormal blood count values (i.e.,
decreased mean corpuscular volume (MCV), decreased
hemoglobin/hematocrit when the MCV is low or normal,
or increased red cell distribution width (RDW) and low or
normal MCV); abnormal appetite (pica); acute or chronic
gastrointestinal blood loss; hematuria; menorrhagia;
malabsorption; status post-gastrectomy; status postgastrojejunostomy; malnutrition; preoperative
autologous blood collection(s); malignant, chronic
inflammatory and infectious conditions associated with
anemia which may present in a similar manner to iron
deficiency anemia; following a significant surgical
procedure where blood loss had occurred and had not
been repaired with adequate iron replacement.
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Indications and Limitations
Test Name
Iron Studies
Policy 190.18
Indications/Limitations
b. The following presentations are examples that may
support the use of these studies for evaluating iron
overload: chronic hepatitis; diabetes;
hyperpigmentation of skin; arthropathy; cirrhosis;
hypogonadism; hypopituitarism; impaired porphyrin
metabolism; heart failure; multiple transfusions;
sideroblastic anemia; thalassemia major;
cardiomyopathy, cardiac dysrhythmias and conduction
disturbances.
2. Follow-up testing may be appropriate to monitor response to
therapy, e.g., oral or parenteral iron, ascorbic acid, and
erythropoietin.
3. Iron studies may be appropriate in patients after treatment for
other nutritional deficiency anemias, such as folate and vitamin
B12, because iron deficiency may not be revealed until such a
nutritional deficiency is treated.
4. Serum ferritin may be appropriate for monitoring iron status in
patients with chronic renal disease with or without dialysis.
5. Serum iron may also be indicated for evaluation of toxic effects
of iron and other metals (e.g., nickel, cadmium, aluminum, lead)
whether due to accidental, intentional exposure or metabolic
causes.
Limitations
1. Iron studies should be used to diagnose and manage iron
deficiency or iron overload states. These tests are not to be used
solely to assess acute phase reactants where disease
management will be unchanged. For example, infections and
malignancies are associated with elevations in acute phase
reactants such as ferritin, and decreases in serum iron
concentration, but iron studies would only be medically
necessary if results of iron studies might alter the management
of the primary diagnosis or might warrant direct treatment of an
iron disorder or condition.
2. If a normal serum ferritin level is documented, repeat testing
would not ordinarily be medically necessary unless there is a
change in the patient's condition, and ferritin assessment is
needed for the ongoing management of the patient. For
example, a patient presents with new onset insulin-dependent
diabetes mellitus and has a serum ferritin level performed for
the suspicion of hemochromatosis. If the ferritin level is normal,
the repeat ferritin for diabetes mellitus would not be medically
necessary.
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Indications and Limitations
Test Name
Indications/Limitations
Iron Studies
Policy 190.18
3. When an End Stage Renal Disease (ESRD) patient is tested for
ferritin, testing more frequently than every three
months requires documentation of medical necessity (e.g., other
than chronic renal failure or renal failure, unspecified).
4. It is ordinarily not necessary to measure both transferrin and
TIBC at the same time because TIBC is an indirect measure of
transferrin. When transferrin is ordered as part of the nutritional
assessment for evaluating malnutrition, it is not necessary to
order other iron studies unless iron deficiency or iron overload is
suspected as well.
5. It is not ordinarily necessary to measure both iron/TIBC (or
transferrin) and ferritin in initial patient testing. If clinically
indicated after evaluation of the initial iron studies, it may be
appropriate to perform additional iron studies either on the
initial specimen or on a subsequently obtained specimen. After a
diagnosis of iron deficiency or iron overload is established, either
iron/TIBC (or transferrin) or ferritin may be medically necessary
for monitoring, but not both.
6. It would not ordinarily be considered medically necessary to do a
ferritin as a preoperative test except in the presence of anemia
or recent autologous blood collections prior to the surgery.
Lipid Testing
Policy 190.23
Indications
The medical community recognizes lipid testing as appropriate for
evaluating atherosclerotic cardiovascular disease. Conditions in
which lipid testing may be indicated include:
•
Assessment of patients with atherosclerotic cardiovascular
disease.
•
Evaluation of primary dyslipidemia.
•
Any form of atherosclerotic disease, or any disease leading to
the formation of atherosclerotic disease.
•
Diagnostic evaluation of diseases associated with altered lipid
metabolism, such as: nephrotic syndrome, pancreatitis, hepatic
disease, and hypo and hyperthyroidism.
•
Secondary dyslipidemia, including diabetes mellitus, disorders of
gastrointestinal absorption, chronic renal failure.
•
Signs or symptoms of dyslipidemias, such as skin lesions.
•
As follow-up to the initial screen for coronary heart disease
(total cholesterol + HDL cholesterol) when total cholesterol is
determined to be high (>240 mg/dL), or borderline-high (200240 mg/dL) plus two or more coronary heart disease risk factors,
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Indications and Limitations
Test Name
Lipid Testing
Policy 190.23
Indications/Limitations
or an HDL cholesterol, <35 mg/dl.
To monitor the progress of patients on anti-lipid dietary
management and pharmacologic therapy for the treatment of
elevated blood lipid disorders, total cholesterol, HDL cholesterol and
LDL cholesterol may be used. Triglycerides may be obtained if this
lipid fraction is also elevated or if the patient is put on drugs (for
example, thiazide diuretics, beta blockers, estrogens,
glucocorticoids, and tamoxifen) which may raise the triglyceride
level.
When monitoring long term anti-lipid dietary or pharmacologic
therapy and when following patients with borderline high total or
LDL cholesterol levels, it may be reasonable to perform the lipid
panel annually. A lipid panel at a yearly interval will usually be
adequate while measurement of the serum total cholesterol or a
measured LDL should suffice for interim visits if the patient does not
have hypertriglyceridemia.
Any one component of the panel or a measured LDL may be
reasonable and necessary up to six times the first year for
monitoring dietary or pharmacologic therapy. More frequent total
cholesterol HDL cholesterol, LDL cholesterol and triglyceride testing
may be indicated for marked elevations or for changes to anti-lipid
therapy due to inadequate initial patient response to dietary or
pharmacologic therapy. The LDL cholesterol or total cholesterol may
be measured three times yearly after treatment goals have been
achieved.
Electrophoretic or other quantitation of lipoproteins may be
indicated if the patient has a primary disorder of lipoid metabolism.
Effective January 1, 2005, the Medicare law expanded coverage to
cardiovascular screening services. Several of the procedures included
in this NCD may be covered for screening purposes subject to
specified frequencies. See 42 CFR 410.17 and section 100, chapter
18, of the Claims Processing Manual, for a full description of this
benefit.
Limitations
Lipid panel and hepatic panel testing may be used for patients with
severe psoriasis which has not responded to conventional therapy
and for which the retinoid etretinate has been prescribed and who
have developed hyperlipidemia or hepatic toxicity. Specific examples
include erythrodermia and generalized pustular type and psoriasis
associated with arthritis.
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xxii
Indications and Limitations
Test Name
Indications/Limitations
Lipid Testing
Policy 190.23
Routine screening and prophylactic testing for lipid disorder are not
covered by Medicare. While lipid screening may be medically
appropriate, Medicare by statute does not pay for it. Lipid testing in
asymptomatic individuals is considered to be screening regardless of
the presence of other risk factors such as family history, tobacco use,
etc.
Once a diagnosis is established, one or several specific tests are
usually adequate for monitoring the course of the disease. Less
specific diagnoses (for example, other chest pain) alone do not
support medical necessity of these tests.
When monitoring long term anti-lipid dietary or pharmacologic
therapy and when following patients with borderline high total or
LDL cholesterol levels, it is reasonable to perform the lipid panel
annually. A lipid panel at a yearly interval will usually be adequate
while measurement of the serum total cholesterol or a measured
LDL should suffice for interim visits if the patient does not have
hypertriglyceridemia.
Any one component of the panel or a measured LDL may be
medically necessary up to six times the first year for monitoring
dietary or pharmacologic therapy. More frequent total cholesterol
HDL cholesterol, LDL cholesterol and triglyceride testing may be
indicated for marked elevations or for changes to anti-lipid therapy
due to inadequate initial patient response to dietary or
pharmacologic therapy. The LDL cholesterol or total cholesterol may
be measured three times yearly after treatment goals have been
achieved.
If no dietary or pharmacological therapy is advised, monitoring is not
necessary.
When evaluating non-specific chronic abnormalities of the liver (for
example, elevations of transaminase, alkaline phosphatase,
abnormal imaging studies, etc.), a lipid panel would generally not be
indicated more than twice per year.
Occult Blood, Fecal
Policy 190.34
Indications
1. To evaluate known or suspected alimentary tract conditions that
might cause bleeding into the intestinal tract.
2. To evaluate unexpected anemia.
3. To evaluate abnormal signs, symptoms, or complaints that might
be associated with loss of blood.
4. To evaluate patient complaints of black or red-tinged stools.
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Indications and Limitations
Test Name
Indications/Limitations
Occult Blood, Fecal
Policy 190.34
Limitations
1. The FOBT is reported once for the testing of up to three separate
specimens (comprising either one or two tests per specimen).
2. In patients who are taking non-steroidal anti-inflammatory drugs
and have a history of gastrointestinal bleeding but no other
signs, symptoms, or complaints associated with gastrointestinal
blood loss, testing for occult blood may generally be appropriate
no more than once every three months.
3. When testing is done for the purpose of screening for colorectal
cancer in the absence of signs, symptoms, conditions, or
complaints associated with gastrointestinal blood loss, report
the HCPCS code for colorectal cancer screening; fecal-occult
blood test, 1-3 simultaneous determinations should be used.
Partial Thromboplastin Time
(PTT)
Policy 190.16
Indications
1. The PTT is most commonly used to quantitate the effect of
therapeutic unfractionated heparin and to regulate its dosing.
Except during transitions between heparin and warfarin therapy,
in general both the PTT and PT are not necessary together to
assess the effect of anticoagulation therapy. PT and PTT must be
justified separately.
2. A PTT may be used to assess patients with signs or symptoms of
hemorrhage or thrombosis. For example: abnormal bleeding,
hemorrhage or hematoma petechiae or other signs of
thrombocytopenia that could be due to disseminated
intravascular coagulation; swollen extremity with or without
prior trauma.
3. A PTT may be useful in evaluating patients who have a history of
a condition known to be associated with the risk of hemorrhage
or thrombosis that is related to the intrinsic coagulation
pathway. Such abnormalities may be genetic or acquired. For
example: dysfibrinogenemia; afibrinogenemia (complete); acute
or chronic liver dysfunction or failure, including Wilson's disease;
hemophilia; liver disease and failure; infectious processes;
bleeding disorders; disseminated intravascular coagulation;
lupus erythematosus or other conditions associated with
circulating inhibitors, e.g., Factor VIII Inhibitor, lupus-like
anticoagulant, etc.; sepsis; von Willebrand's disease; arterial and
venous thrombosis, including the evaluation of hypercoagulable
states; clinical conditions associated with nephrosis or renal
failure; other acquired and congenital coagulopathies as well as
thrombotic states.
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Indications and Limitations
Test Name
Indications/Limitations
Partial Thromboplastin Time
(PTT)
Policy 190.16
4. A PTT may be used to assess the risk of thrombosis or
hemorrhage in patients who are going to have a medical
intervention known to be associated with increased risk of
bleeding or thrombosis. An example is as follows: evaluation
prior to invasive procedures or operations of patients with
personal or family history of bleeding or who are on heparin
therapy.
Limitations
1. The PTT is not useful in monitoring the effects of warfarin on a
patient's coagulation routinely. However, a PTT may be ordered
on a patient being treated with warfarin as heparin therapy is
being discontinued. A PTT may also be indicated when the PT is
markedly prolonged due to warfarin toxicity.
2. The need to repeat this test is determined by changes in the
underlying medical condition and/or the dosing of heparin.
3. Testing prior to any medical intervention associated with a risk
of bleeding and thrombosis (other than thrombolytic therapy)
will generally be considered medically necessary only where
there are signs or symptoms of a bleeding or thrombotic
abnormality or a personal history of bleeding, thrombosis or a
condition associated with a coagulopathy. Hospital/clinic-specific
policies, protocols, etc., in and of themselves, cannot alone
justify coverage.
Prostate Specific Antigen (PSA)
Policy 190.31
Indications
PSA is of proven value in differentiating benign from malignant
disease in men with lower urinary tract signs and symptoms (e.g.,
hematuria, slow urine stream, hesitancy, urgency, frequency,
nocturia and incontinence) as well as with patients with palpably
abnormal prostate glands on physician exam, and in patients with
other laboratory or imaging studies that suggest the possibility of a
malignant prostate disorder. PSA is also a marker used to follow the
progress of prostate cancer once a diagnosis has been established,
such as in detecting metastatic or persistent disease in patients who
may require additional treatment. PSA testing may also be useful in
the differential diagnosis of men presenting with as yet undiagnosed
disseminated metastatic disease.
Limitations
Generally, for patients with lower urinary tract signs or symptoms,
the test is performed only once per year unless there is a change in
the patient's medical condition.
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Indications and Limitations
Test Name
Indications/Limitations
Prostate Specific Antigen (PSA)
Policy 190.31
Testing with a diagnosis of in situ carcinoma is not reasonably done
more frequently than once, unless the result is abnormal, in which
case the test may be repeated once.
Prothrombin Time
Policy 190.17
Indications
1. A PT may be used to assess patients taking warfarin. The
prothrombin time is generally not useful in monitoring patients
receiving heparin who are not taking warfarin.
2. A PT may be used to assess patients with signs or symptoms of
abnormal bleeding or thrombosis. For example: swollen
extremity with or without prior trauma; unexplained bruising;
abnormal bleeding, hemorrhage or hematoma; petechiae or
other signs of thrombocytopenia that could be due to
disseminated intravascular coagulation.
3. A PT may be useful in evaluating patients who have a history of a
condition known to be associated with the risk of bleeding or
thrombosis that is related to the extrinsic coagulation pathway.
Such abnormalities may be genetic or acquired. For example:
dysfibrinogenemia; afibrinogenemia (complete); acute or
chronic liver dysfunction or failure, including Wilson's disease
and Hemochromatosis; disseminated intravascular coagulation
(DIC); congenital and acquired deficiencies of factors II, V, VII, X;
vitamin K deficiency; lupus erythematosus; hypercoagulable
state; paraproteinemia; lymphoma; amyloidosis; acute and
chronic leukemias; plasma cell dyscrasia; HIV infection;
malignant neoplasms; hemorrhagic fever; salicylate poisoning;
obstructive jaundice; intestinal fistula; malabsorption syndrome;
colitis; chronic diarrhea; presence of peripheral venous or
arterial thrombosis or pulmonary emboli or myocardial
infarction; patients with bleeding or clotting tendencies; organ
transplantation; presence of circulating coagulation inhibitors.
4. A PT may be used to assess the risk of hemorrhage or
thrombosis in patients who are going to have a medical
intervention known to be associated with increased risk of
bleeding or thrombosis. For example: evaluation prior to
invasive procedures or operations of patients with personal
history of bleeding or a condition associated with coagulopathy
prior to the use of thrombolytic medication.
PeaceHealth Laboratories | Indications and Limitations
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Indications and Limitations
Test Name
Indications/Limitations
Prothrombin Time
Policy 190.17
Limitations
1. When an ESRD patient is tested for PT, testing more frequently
than weekly requires documentation of medical necessity, e.g.,
other than chronic renal failure or renal failure, unspecified.
2. The need to repeat this test is determined by changes in the
underlying medical condition and/or the dosing of warfarin. In a
patient on stable warfarin therapy, it is ordinarily not necessary
to repeat testing more than every two to three weeks. When
testing is performed to evaluate a patient with signs or
symptoms of abnormal bleeding or thrombosis and the initial
test result is normal, it is ordinarily not necessary to repeat
testing unless there is a change in the patient's medical status.
3. Since the INR is a calculation, it will not be paid in addition to the
PT when expressed in seconds, and is considered part of the
conventional prothrombin time.
4. Testing prior to any medical intervention associated with a risk
of bleeding and thrombosis (other than thrombolytic therapy)
will generally be considered medically necessary only where
there are signs or symptoms of a bleeding or thrombotic
abnormality or a personal history of bleeding, thrombosis or a
condition associated with a coagulopathy. Hospital/clinic-specific
policies, protocols, etc., in and of themselves, cannot alone
justify coverage.
PeaceHealth Laboratories | Indications and Limitations
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Indications and Limitations
Test Name
Indications/Limitations
Sexually Transmitted Infections
(STI’s)
Policy 210.10
Indications
CMS has determined that the evidence is adequate to conclude that
screening for chlamydia, gonorrhea, syphilis, and hepatitis B, as well
as HIBC to prevent STIs, consistent with the grade A and B
recommendations by the USPSTF, is reasonable and necessary for
the early detection or prevention of an illness or disability and is
appropriate for individuals entitled to benefits under Part A or
enrolled under Part B.
Therefore, effective for claims with dates of services on or after
November 8, 2011, CMS will cover screening for these USPSTFindicated STIs with the appropriate Food and Drug Administration
(FDA)-approved/cleared laboratory tests, used consistent with FDAapproved labeling, and in compliance with the Clinical Laboratory
Improvement Act (CLIA) regulations, when ordered by the primary
care physician or practitioner, and performed by an eligible
Medicare provider for these services.
Screening for chlamydia and gonorrhea:
• Pregnant women who are 24 years old or younger when the
diagnosis of pregnancy is known, and then repeat screening
during the third trimester if high-risk sexual behavior has
occurred since the initial screening test.
• Pregnant women who are at increased risk for STIs when the
diagnosis of pregnancy is known, and then repeat screening
during the third trimester if high-risk sexual behavior has
occurred since the initial screening test.
• Women at increased risk for STIs annually.
Screening for syphilis:
• Pregnant women when the diagnosis of pregnancy is known;
and then repeat screening during the third trimester and at
delivery if high-risk sexual behavior has occurred since the
previous screening test.
• Men and women at increased risk for STIs annually.
Screening for hepatitis B:
• Pregnant women at the first prenatal visit when the
diagnosis of pregnancy is known, and then rescreening at
time of delivery for those with new or continuing risk
factors.
In addition, effective for claims with dates of service on or after
November 8, 2011, CMS will cover up to two individual 20- to 30minute, face-to-face counseling sessions annually for Medicare
beneficiaries for HIBC to prevent STIs, for all sexually active
adolescents, and for adults at increased risk for STIs, if referred for
PeaceHealth Laboratories | Indications and Limitations
xxviii
Indications and Limitations
Test Name
Indications/Limitations
Sexually Transmitted Infections
(STI’s)
Policy 210.10
this service by a primary care physician or practitioner, and provided
by a Medicare eligible primary care provider in a primary care
setting. Coverage of HIBC to prevent STIs is consistent with the
USPSTF recommendation.
HIBC is defined as a program intended to promote sexual risk
reduction or risk avoidance, which includes each of these broad
topics, allowing flexibility for appropriate patient-focused elements:
• education
• skills training
• guidance on how to change sexual behavior
The high/increased risk individual sexual behaviors, based on the
USPSTF guidelines, include any of the following:
• Multiple sex partners
• Using barrier protection inconsistently
• Having sex under the influence of alcohol or drugs
• Having sex in exchange for money or drugs
• Age (24 years of age or younger and sexually active for
women for chlamydia and gonorrhea)
• Having an STI within the past year
• IV drug use (for hepatitis B only)
• In addition for men – men having sex with men (MSM) and
engaged in high risk sexual behavior, but no regard to age
In addition to individual risk factors, in concurrence with the USPSTF
recommendations, community social factors such as high prevalence
of STIs in the community populations should be considered in
determining high/increased risk for chlamydia, gonorrhea, syphilis,
and for recommending HIBC.
High/increased risk sexual behavior for STIs is determined by the
primary care provider by assessing the patient’s sexual history which
is part of any complete medical history, typically part of an annual
wellness visit or prenatal visit and considered in the development of
a comprehensive prevention plan. The medical record should be a
reflection of the service provided.
For the purposes of this NCD, a primary care setting is defined as the
provision of integrated, accessible health care services by clinicians
who are accountable for addressing a large majority of personal
health care needs, developing a sustained partnership with patients,
and practicing in the context of family and community. Emergency
departments, inpatient hospital settings, ambulatory surgical
centers, independent diagnostic testing facilities, skilled nursing
PeaceHealth Laboratories | Indications and Limitations
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Indications and Limitations
Test Name
Indications/Limitations
Sexually Transmitted Infections
(STI’s)
Policy 210.10
facilities, inpatient rehabilitation facilities, clinics providing a limited
focus of health care services, and hospice are examples of settings
not considered primary care settings under this definition.
Thyroid Testing
Policy 190.22
Indications
Thyroid function tests are used to define hyper function,
euthyroidism, or hypofunction of thyroid disease. Thyroid testing
may be reasonable and necessary to:
•
Distinguish between primary and secondary hypothyroidism;
•
Confirm or rule out primary hypothyroidism;
•
Monitor thyroid hormone levels (for example, patients with
goiter, thyroid nodules, or thyroid cancer);
•
Monitor drug therapy in patients with primary hypothyroidism;
•
Confirm or rule out primary hyperthyroidism; and
•
Monitor therapy in patients with hyperthyroidism.
Thyroid function testing may be medically necessary in patients with
disease or neoplasm of the thyroid and other endocrine glands.
Thyroid function testing may also be medically necessary in patients
with metabolic disorders; malnutrition; hyperlipidemia; certain types
of anemia; psychosis and non-psychotic personality disorders;
unexplained depression; ophthalmologic disorders; various cardiac
arrhythmias; disorders of menstruation; skin conditions; myalgias;
and a wide array of signs and symptoms, including alterations in
consciousness; malaise; hypothermia; symptoms of the nervous and
musculoskeletal system; skin and integumentary system; nutrition
and metabolism; cardiovascular; and gastrointestinal system.
It may be medically necessary to do follow-up thyroid testing in
patients with a personal history of malignant neoplasm of the
endocrine system and in patients on long-term thyroid drug therapy.
Limitations
Testing may be covered up to two times a year in clinically stable
patients; more frequent testing may be reasonable and necessary
for patients whose thyroid therapy has been altered or in whom
symptoms or signs of hyperthyroidism or hypothyroidism are noted.
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Indications and Limitations
Test Name
Urinalysis
Policy L33034
Indications/Limitations
Urinalysis is a commonly used physical, chemical, and/or microscopic
examination of the urine used to detect renal or urinary tract disease
or systemic disorders manifested by or through the urinary system.
In order for Medicare coverage to be provided for urinalysis, the
patient must have signs or symptoms of a kidney/urinary tract
disorder or a condition, which is known to affect the kidney/urinary
tract.
The following is a list of conditions in which urinalysis may be
considered medically reasonable and necessary:
•
•
•
•
•
•
•
•
•
The patient has symptoms suggestive of possible
kidney/urinary tract disorder, e.g., dysuria, frequency,
hesitancy, nocturia, urgency, flank pain, pelvic pain,
abdominal pain, etc.
The patient exhibits signs of kidney/urinary tract disorder
such as hematuria, discoloration of urine, edema, and
malodorous urine.
The patient has been recently treated or is under treatment
for urinary tract disorder and follow-up urinalysis is
necessary to evaluate the patient.
The patient has a condition known to affect the kidneys or
urinary tract, e.g., hypertension, diabetes mellitus, known
renal disease, collagen vascular disease and a urinalysis is
necessary to evaluate the patient.
The patient is undergoing treatment with medication known
to potentially adversely affect the kidneys, e.g., gold
therapy.
The patient has sustained trauma suggestive of possible
kidney/urinary tract injury.
The patient has unexplained fever.
The patient is pregnant and urinalysis is being done as part
of standard prenatal care.
The patient is pregnant and urinalysis is being done to
screen for pre-eclampsia.
Urinalysis can be covered as part of the evaluation of a dehydrated
patient.
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Indications and Limitations
Test Name
Indications/Limitations
Urine Culture, Bacterial/
Sensitivity Studies
Policy 190.12
Indications
1. A patient's urinalysis is abnormal suggesting urinary tract
infection, for example, abnormal microscopic (hematuria, pyuria,
bacteriuria); abnormal biochemical urinalysis (positive leukocyte
esterase, nitrite, protein, blood); a Gram's stain positive for
microorganisms; positive bacteriuria screen by a non-culture
technique; or other significant abnormality of a urinalysis. While
it is not essential to evaluate a urine specimen by one of these
methods before a urine culture is performed, certain clinical
presentations with highly suggestive signs and symptoms may
lend themselves to an antecedent urinalysis procedure where
follow-up culture depends upon an initial positive or abnormal
test result.
2. A patient has clinical signs and symptoms indicative of a possible
urinary tract infection (UTI). Acute lower UTI may present with
urgency, frequency, nocturia, dysuria, discharge or incontinence.
These findings may also be noted in upper UTI with additional
systemic symptoms (for example, fever, chills, lethargy); or pain
in the costovertebral, abdominal, or pelvic areas. Signs and
symptoms may overlap considerably with other inflammatory
conditions of the genitourinary tract (for example, prostatitis,
urethritis, vaginitis, or cervicitis). Elderly or
immunocompromised patients, or patients with neurologic
disorders may present atypically (for example, general debility,
acute mental status changes, declining functional status).
3. The patient is being evaluated for suspected urosepsis, fever of
unknown origin, or other systemic manifestations of infection
but without a known source. Signs and symptoms used to define
sepsis have been well established.
4. A test-of cure is generally not indicated in an uncomplicated
infection. However, it may be indicated if the patient is being
evaluated for response to therapy and there is a complicating
co-existing urinary abnormality including structural or functional
abnormalities, calculi, foreign bodies, or ureteral/renal stents or
there is clinical or laboratory evidence of failure to respond as
described in Indications 1 and 2.
5. In surgical procedures involving major manipulations of the
genitourinary tract, preoperative examination to detect occult
infection may be indicated in selected cases (for example, prior
to renal transplantation, manipulation or removal of kidney
stones, or transurethral surgery of the bladder or prostate).
PeaceHealth Laboratories | Indications and Limitations
xxxii
Indications and Limitations
Test Name
Indications/Limitations
Urine Culture, Bacterial/
Sensitivity Studies
Policy 190.12
6. Urine culture may be indicated to detect occult infection in renal
transplant recipients on immunosuppressive therapy.
Limitations
1. CPT 87086 may be used one time per encounter.
2. Colony count restrictions on coverage of CPT 87088 do not apply
as they may be highly variable according to syndrome or other
clinical circumstances (for example, antecedent therapy,
collection time, degree of hydration).
3. CPT 87088, 87184, and 87186 may be used multiple times in
association with or independent of 87086, as urinary tract
infections may be polymicrobial.
4. Testing for asymptomatic bacteriuria as part of a prenatal
evaluation may be medically appropriate but is considered
screening and, therefore, not covered by Medicare. The US
Preventive Services Task Force has concluded that screening for
asymptomatic bacteriuria outside of the narrow indication for
pregnant women is generally not indicated. There are
insufficient data to recommend screening in ambulatory elderly
patients including those with diabetes. Testing may be clinically
indicated on other grounds including likelihood of recurrence or
potential adverse effects of antibiotics, but is considered
screening in the absence of clinical or laboratory evidence of
infection.
Vitamin D Assay
Policy L32132
Indications:
Measurement of 25-OH Vitamin D, CPT 82306, level is indicated for
patients with:
•
•
•
•
•
•
•
•
•
•
•
chronic kidney disease stage III or greater
cirrhosis
hypocalcemia
hypercalcemia
hypercalciuria
hypervitaminosis D
parathyroid disorders
malabsorption states
obstructive jaundice
osteomalacia
osteoporosis if (continued on next page)
i. T score on DEXA scan <-2.5 or
ii. History of fragility fractures or
PeaceHealth Laboratories | Indications and Limitations
xxxiii
Indications and Limitations
Test Name
Indications/Limitations
iii. FRAX > 3% 10-year probability of hip fracture or
20% 10-year probability of other major osteoporotic
fracture or
iv. FRAX > 3% (any fracture) with T-score <-1.5 or
v. Initiating bisphosphanate therapy (Vit D level
should be determined and managed as necessary
before bisphosphonate is initiated)
Vitamin D Assay
Policy L32132
•
•
•
osteosclerosis/petrosis
rickets
Vitamin D deficiency on replacement therapy related to a
condition listed above; to monitor the efficacy of treatment.
Measurement of 1, 25-OH Vitamin D, CPT 82652, level is indicated
for patients with:
•
•
•
•
•
unexplained hypercalcemia (suspected granulomatous
disease or lymphoma)
unexplained hypercalciuria (suspected granulomatous
disease or lymphoma)
suspected genetic childhood rickets
suspected tumor-induced osteomalacia
nephrolithiasis or hypercalciuria
Limitations:
Testing may not be used for routine or other screening.
Both assays of vitamin D need not be performed for each of the
above conditions. Often, one type is more appropriate for a certain
disease state than another. The most common type of vitamin D
deficiency is 25-OH vitamin D. A much smaller percentage of 1,25
dihydroxy vitamin D deficiency exists; mostly, in those with renal
disease. Documentation must justify the test(s) chosen for a
particular disease entity. Various component sources of 25-OH
vitamin D, such as stored D or diet-derived D, should not be billed
separately.
Once a beneficiary has been shown to be vitamin D deficient, further
testing may be medically necessary only to ensure adequate
replacement has been accomplished. If Vitamin D level is between
20 and 50 ng/dl and patient is clinically stable, repeat testing is often
unnecessary; if performed, documentation must clearly indicate the
necessity of the test. If level <20 ng/dl or > 60 ng/dl, a subsequent
level(s) may be reimbursed until the level is within the normal range.
PeaceHealth Laboratories | Indications and Limitations
xxxiv
Alpha-fetoprotein
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
82105
ICD-9 CODES
TEST NAME
Alpha-fetoprotein; serum
ICD-9 DESCRIPTIONS
Chronic viral hepatitis B with hepatic coma, with or without mention of
hepatitis delta
070.22–070.23
070.32–070.33
070.44
070.54
095.3
121.1
121.3
155.0–155.2
164.2–164.9
183.0
186.0
186.9
197.1
197.7
198.6
198.82
209.20-209.27, 209.29
209.70
209.71
209.72
209.73
209.74
209.75
209.79
211.5
235.3
272.2
273.4
275.01
275.02
275.03
275.09
275.1
277.00
277.03
277.6
285.0
Chronic viral hepatitis B without mention of hepatic coma, with or without
mention of hepatitis delta
Chronic hepatitis C with hepatic coma
Chronic hepatitis C without mention of hepatic coma
Syphilis of liver
Clonorchiasis
Fascioliasis
Malignant neoplasm of the liver and intrahepatic bile ducts
Malignant neoplasm of the mediastinum
Malignant neoplasm, ovary
Malignant neoplasm of undescended testis
Malignant neoplasm, other and unspecific testis
Secondary malignant neoplasm of mediastinum
Secondary malignant neoplasm of liver
Secondary malignant neoplasm of ovary
Secondary malignant neoplasm, genital organs
Malignant carcinoid tumors of other and unspecified sites
Secondary neuroendocrine tumor, unspecified site
Secondary neuroendocrine tumor of distant lymph nodes
Secondary neuroendocrine tumor of liver
Secondary neuroendocrine tumor of bone
Secondary neuroendocrine tumor of peritoneum
Secondary Merkel cell carcinoma
Secondary neuroendocrine tumor of other sites
Benign neoplasm of liver and biliary passages
Neoplasm of uncertain behavior of liver and biliary passages
Mixed hyperlipidemia
Alpha-1-antitrypsin deficiency
Hereditary hemochromatosis
Hemochromatosis due to repeated red blood cell transfusions
Other hemochromatosis
Other disorders of iron metabolism
Disorder of copper metabolism
Cystic Fibrosis without mention of meconium ileus
Cystic fibrosis with gastrointestinal manifestations
Other deficiencies of circulating enzymes
Sideroblastic Anemia
PeaceHealth Laboratories | Medicare Coverage Policies
1
Alpha-fetoprotein….con’t
82105
338.3
Neoplasm related to pain (acute) (chronic)
414.4
Coronary atherosclerosis due to calcified coronary lesion
444.01
Saddle embolus of abdominal aorta
444.09
Other arterial embolism and thrombosis of abdominal aorta
571.2
Alcoholic cirrhosis of liver
571.40
Chronic hepatitis, unspecified
571.41
Chronic persistent hepatitis
571.42
Autoimmune hepatitis
571.49
Other chronic hepatitis
571.5
Cirrhosis of liver without mention of alcohol
573.5
Hepatopulmonary syndrome
608.89
Other specified disorders of male genital organs
793.11
Solitary pulmonary nodule
793.19
Other nonspecific abnormal finding of lung field
793.2
Non-specific abnormal findings of other intrathoracic organs
793.3
Non-specific abnormal findings of biliary tract
793.6
Non-specific abnormal findings of abdominal area, including retro peritoneum
795.89
Other abnormal tumor markers
V10.07
Personal history of malignant neoplasm, liver
V10.43
Personal history of malignant neoplasm, ovary
V10.47
Personal history of malignant neoplasm, testis
V86.0
Estrogen receptor positive status [ER+]
V86.1
Estrogen receptor negative status [ER-]
PeaceHealth Laboratories | Medicare Coverage Policies
2
B-type Natriuretic Peptide (BNP)
Policy # L31568
Policy Type: LCD (Local Coverage Decision)
CPT CODE(S)
83880
ICD-9 CODES
402.01
402.11
402.91
404.01
404.03
404.11
404.13
404.91
404.93
410.62
410.72
410.82
410.92
423.2
425.4
428.0
428.1
428.20
428.21
428.22
428.23
428.30
428.31
428.32
428.33
428.40
428.41
428.42
428.43
428.9
491.21
491.22
493.22
493.92
519.11
TEST NAME
Natriuretic peptide
ICD-9 DESCRIPTIONS
Malignant hypertensive heart disease with heart failure
Benign hypertensive heart disease with heart failure
Unspecified hypertensive heart disease with heart failure
Hypertensive heart and chronic kidney disease, malignant, with heart failure
and with chronic kidney disease Stage I through Stage IV, or unspecified
Hypertensive heart and chronic kidney disease, malignant, with heart failure
and with chronic kidney disease Stage V or end stage renal disease
Hypertensive heart and chronic kidney disease, benign, with heart failure and
with chronic kidney disease Stage I through Stage IV, or unspecified
Hypertensive heart and chronic kidney disease, benign, with heart failure and
chronic kidney disease Stage V or end stage renal disease
Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and with chronic kidney disease Stage I through Stage IV, or unspecified
Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and chronic kidney disease Stage V or end stage renal disease
True posterior wall infarction subsequent episode of care
Subendocardial infarction subsequent episode of care
Acute myocardial infarction of other specified sites subsequent episode of care
Acute myocardial infarction of unspecified site subsequent episode of care
Constructive pericarditis
Other primary cardiomyopathies
Congestive heart failure unspecified
Left heart failure
Unspecified systolic heart failure
Acute systolic heart failure
Chronic systolic heart failure
Acute on chronic systolic heart failure
Unspecified diastolic heart failure
Acute diastolic heart failure
Chronic diastolic heart failure
Acute on chronic diastolic heart failure
Unspecified combined systolic and diastolic heart failure
Acute combined systolic and diastolic heart failure
Chronic combined systolic and diastolic heart failure
Acute on chronic combined systolic and diastolic heart failure
Heart failure unspecified
Obstructive chronic bronchitis with (acute) exacerbation
Obstructive chronic bronchitis with acute bronchitis
Chronic obstructive asthma with (acute) exacerbation
Asthma unspecified with (acute) exacerbation
Acute bronchospasm
PeaceHealth Laboratories | Medicare Coverage Policies
3
B-type Natuiuretic
Peptide
(BNP)…(con’t)
786.00
786.02
786.05
786.06
786.07
786.09
83880
Respiratory abnormality unspecified
Orthopnea
Shortness of breath
Tachypnea
Wheezing
Respiratory abnormality other
PeaceHealth Laboratories | Medicare Coverage Policies
4
ICD-9 codes listed are NON-COVERED codes
Blood Counts
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
85004
TEST NAME
Automated differential WBC count
Blood smear, microscopic examination with manual differential WBC
count
Blood smear, microscopic examination without manual differential
parameters
Spun microhematocrit
Hematocrit (Hct)
Hemoglobin
CBC, automated (Hgb, Hct, RBC, WBC and platelet count) and automated
differential WBC count
CBC, automated (Hgb, Hct, RBC, WBC and platelet count)
Manual cell count (erythrocyte, leukocyte, or platelet)
Leukocyte (WBC), automated
Platelet, automated
85007
85008
85013
85014
85018
85025
85027
85032
85048
85049
ICD–9–CM Codes COVERED by Medicare Program:
Any code NOT listed in either of the ICD–9 sections below.
NON-COVERED
ICD-9 CODES
078.10–078.19
210.0–210.9
214.0
216.0–216.9
217
222.0–222.9
224.0
230.0
232.0–232.9
300.00–300.09
301.0–301.9
302.0–302.9
307.0
307.20–307.23
307.3
307.80–307.89
312.00–312.9
313.0–313.9
314.00–314.9
338.0
338.11
ICD-9 DESCRIPTIONS
Viral warts
Benign neoplasm of lip, oral cavity, and pharynx
Lipoma, skin and subcutaneous tissue of face
Benign neoplasm of skin
Benign neoplasm of breast
Benign neoplasm of male genital organs
Benign neoplasm of eye
Carcinoma in situ of lip, oral cavity and pharynx
Carcinoma in situ of skin
Neurotic disorders
Personality disorders
Sexual deviations and disorders
Stammering and stuttering
Tics
Stereotyped repetitive movements
Psychalgia
Disturbance of conduct, not elsewhere classified
Disturbance of emotions specific to childhood and adolescence
Hyperkinetic syndrome of childhood
Central pain syndrome
Acute pain due to trauma
PeaceHealth Laboratories | Medicare Coverage Policies
5
Blood Counts…….con’t
85004, 85007, 85008, 85013, 85014, 85018
NON-COVERED ICD-9 CODES
338.12
338.18
338.19
338.21
338.22
338.28
338.29
338.4
363.30–363.35
363.40–363.43
363.50–363.57
363.70–363.9
366.00–366.9
367.0–367.9
371.00–371.9
373.00–373.9
375.00–375.9
376.21–376.22
376.40-376.47
376.50-376.52
376.6
376.81-376.82
376.89
376.9
377.10–377.16
377.21–377.24
384.20–384.25
384.81–384.82
385.00–385.9
387.0–387.9
388.00–388.32
388.40-388.45
388.5
389.00–389.06, 389.08
389.10-389.18
389.20-389.22
389.7
389.8, 389.9
440.0–440.1
443.81–443.9
448.1
457.0
470
471.0–471.9
478.0
85025, 85027, 85032, 85048, 85049
Acute post-thoracotomy pain
Other acute postoperative pain
Other acute pain
Chronic pain due to trauma
Chronic post-thoracotomy pain
Other chronic postoperative pain
Other chronic pain
Chronic pain syndrome
Chorioretinal scars
Choroidal degeneration
Hereditary choroidal dystrophies
Choroidal detachment
Cataract
Disorders of refraction and accommodation
Corneal opacity and other disorders of cornea
Inflammation of eyelids
Disorders of lacrimal system
Endocrine exophthalmos
Deformity of orbit
Enophthalmos
Retained (old)foreign body following penetrating wound of orbit
Orbital cysts; myopathy of extraocular muscles
Other orbital disorders
Unspecified disorder of orbit
Optic atrophy
Other disorders of optic disc
Perforation of tympanic membrane
Other specified disorders of tympanic membrane
Other disorders of middle ear and mastoid
Otosclerosis
Degenerative and vascular disorders of ear; noise effects on inner ear; sudden
hearing loss, unspecified; and tinnitus
Other abnormal auditory perception
Disorders of acoustic nerve
Conductive hearing loss
Sensorineural hearing loss
Mixed hearing loss
Deaf, non-speaking, not elsewhere classifiable
Hearing loss
Atherosclerosis of aorta and renal artery
Peripheral vascular disease
Capillary nevus, non neoplastic
Postmastectomy lymphedema syndrome
Deviated nasal septum
Nasal polyps
Hypertrophy of nasal turbinates
PeaceHealth Laboratories | Medicare Coverage Policies
6
Blood Counts…….con’t
85004, 85007, 85008, 85013, 85014, 85018
NON-COVERED ICD-9 CODES
478.11
478.19
478.4
520.0–520.9
521.00–521.15, 521.20521.25, 521.30-521.35,
521.40-521.42, 521.49,
521.5-521.7, 521.81,
521.89, 521.9
524.00–524.9
525.0, 525.10-525.13,
525.19, 525.20-525.26,
525.3, 525.40-525.44,
525.50-525.54, 525.60525.67, 525.69
525.71
525.72
525.73
525.8
525.9
526.0–526.3
526.61
526.62
526.63
526.69
527.6–527.9
575.6
600.00-600.91
603.0
603.8
603.9
605
606.0-606.1
608.1
608.20
608.21
608.22
608.23
608.24
608.3
610.0–610.9
611.1–611.6
611.9
616.2
85025, 85027, 85032, 85048, 85049
Nasal mucositis (ulcerative)
Other disease of nasal cavity and sinuses
Polyp of vocal cord or larynx
Disorders of tooth development and eruption
Diseases of hard tissues of teeth
Dentofacial anomalies, including malocclusion
Other diseases and conditions of teeth and supporting structures
Osseointegration failure of dental implant
Post-osseointegration biological failure of dental implant
Post-osseointegration mechanic failure of dental implant
Other specified disorders of the teeth and supporting structures
Unspecified disorder of the teeth and supporting structures
Diseases of the jaws
Perforation of root canal space
Endodontic overfill
Endodontic underfill
Other periadicular pathology associated with previous endodontic treatment
Diseases of the salivary glands
Cholesterolosis of gallbladder
Hyperplasia of prostate
Encysted hydrocele
Other specified types of hydrocele
Hydrocele, unspecified
Redundant prepuce and phimosis
Infertility, male azoospermia and oligospermia
Spermatocele
Torsion of testis, unspecified
Extravaginal torsion of spermatic cord
Intravaginal torsion of spermatic cord
Torsion of appendix testis
Torsion of appendix epididymis
Atrophy of testis
Benign mammary dysplasia
Other disorders of breast
Unspecified breast disorder
Cyst of Bartholin’s gland
PeaceHealth Laboratories | Medicare Coverage Policies
7
Blood Counts……con’t
85004, 85007, 85008, 85013, 85014, 85018
NON-COVERED ICD-9 CODES
618.00–618.05, 618.09,
618.1-618.7, 618.81618.83, 618.84, 618.89,
618.9
620.0–620.3
621.6–621.7
627.2–627.9
628.0–628.9
676.00–676.94
691.0–691.8
692.0–692.9
700
701.0–701.9
702.0–702.8
703.9
706.0–706.9
709.00–709.4
715.00–715.98
716.00–716.99
718.00–718.99
726.0–726.91
727.00–727.9
728.10–728.85
732.0–732.9
733.00–733.09
734
735.0–735.9
736.00–736.9
737.0–737.9
738.0–738.9
739.0–739.9
799.81
830.0–832.19
832.2
833.00-833.19
834.00-834.12
835.00-835.13
836.0-836.69
837.0-837.1
838.00-838.19
839.00-839.9
840.0–848.9
905.0–909.9
910.0–919.9
930.0–932
955.0–957.9
85025, 85027, 85032, 85048, 85049
Genital prolapse
Non-inflammatory disorders of ovary, fallopian tube, and broad ligament
Malposition or inversion of uterus
Menopausal and postmenopausal disorders
Infertility, female
Other disorders of breast associated with childbirth and disorders of lactation
Atopic dermatitis and related disorders
Contact dermatitis and other eczema
Corns and callosities
Other hypertrophic and atrophic conditions of skin
Other dermatoses
Unspecified disease of nail
Diseases of sebaceous glands
Other disorders of skin and subcutaneous tissue
Osteoarthrosis
Other and unspecified arthropathies
Other derangement of joint
Peripheral esthesiopathies and allied syndromes
Other disorders of synovium, tendon, and bursa
Disorders of muscle ligament and fascia
Osteochondropathies
Osteoporosis
Flat foot
Acquired deformities of toe
Other acquired deformities of limb
Curvature of spine
Other acquired deformity
Nonallopathic lesions, not elsewhere classified
Decreased libido
Dislocation of jaw, shoulder, and elbow
Nursemaid’s elbow
Dislocation of wrist
Dislocation of finger
Dislocation of hip
Dislocation of knee
Dislocation of ankle
Dislocation of foot
Other, multiple and ill-defined dislocations
Sprains and strains
Late effects of musculoskeletal and connective tissue injuries
Superficial injuries
Foreign body on external eye, in ear, in nose
Injury to peripheral nerve
PeaceHealth Laboratories | Medicare Coverage Policies
8
Blood Counts…….con’t
85004, 85007, 85008, 85013, 85014, 85018
NON-COVERED ICD-9 CODES
V03.0–V06.9
V11.0–V11.3
V11.4
V11.8-V11.9
V14.0–V14.8
V16.0
V16.3
V21.0–V21.9
V25.01–V25.04, V25.09
V25.11
V25.12
V25.13
V25.2-V25.3, V25.40V25.43, V25.49, V25.5,
V25.8, V25.9
V26.0–V26.39
V26.41
V26.42
V26.49
V26.51
V26.52
V26.81
V26.82
V26.89-V26.9
V40.0–V40.9
V41.0–V41.9
V43.0–V43.1
V44.0–V44.9
V45.00–V45.02, V45.09
V45.11
V45.12
V45.2-V45.4, V45.51,
V45.52, V45.59, V45.61,
V45.69, V45.71-V45.79,
V45.81-V45.85, V45.86,
V45.89
V48.0–V48.9
V49.0–V49.85
V49.86
V49.87
V49.89-V49.9
V51.0
V51.8
V52.0–V52.9
V53.01–V53.09
85025, 85027, 85032, 85048, 85049
Need for prophylactic vaccination
Personal history of mental disorder, schizophrenia, affective disorders,
neurosis, and alcoholism
Personal history of combat and operational stress reaction
Personal history of other and unspecified mental disorders
Personal history of allergy to medicinal agents
Family history of malignant neoplasm, gastrointestinal tract
Family history of malignant neoplasm, breast
Constitutional states in development
Encounter for contraceptive management; general counseling and advice
Encounter for insertion of intrauterine contraceptive device
Encounter for removal of intrauterine contraceptive device
Encounter for removal and reinsertion of intrauterine contraceptive device
Encounter for sterilization; menstrual extraction; surveillance of previously
prescribed contraceptive methods; and insertion of implantable subdermal
contraceptive; other specified and unspecified contraceptive management
Procreative management
Other procreative counseling and advice using natural family planning
Encounter for fertility preservation counseling
Other procreative management, counseling and advice
Tubal ligation status
Vascectomy status
Encounter for assisted reproductive fertility procedure cycle
Encounter for fertility preservation procedure
Other specified and unspecified procreative management
Mental and behavioral problems
Problems with special senses and other special functions
Organ or tissue replaced by other means, eye globe or lens
Artificial opening status
Other post-surgical states
Renal dialysis status
Non-compliance with renal dialysis
Other post-surgical states
Problems with head, neck, and trunk
Other conditions influencing health status
Do not resuscitate status
Physical restraints status
Other specified and unspecified conditions influencing health status
Encounter for breast reconstruction following mastectomy
Other aftercare involving the use of plastic surgery
Fitting and adjustment of prosthetic device and implant
Fitting and adjustment of devices related to nervous system and special senses
PeaceHealth Laboratories | Medicare Coverage Policies
9
Blood Counts…….con’t
85004, 85007, 85008, 85013, 85014, 85018
NON-COVERED ICD-9 CODES
V53.1
V53.31–V53.39
V53.4
V53.50
V53.51
V53.59
V53.6
V53.7
V53.8
V53.90-V53.99
V54.01–V54.9
V55.0–V55.9
V57.0–V57.2
V57.3
V57.4-V57.9
V58.5
V59.01–V59.9
V61.01
V61.02
V61.03
V61.04
V61.05
V61.06
V61.07
V61.08
V61.09
V61.10
V61.11
V61.12
V61.20
V61.21
V61.22
V61.23
V61.24
V61.25
V61.29
V61.3
V61.41
V61.42
V61.49, V61.5-V61.9
V62.21
V62.22
V62.29
V62.3-V62.84
85025, 85027, 85032, 85048, 85049
Fitting and adjustment of spectacles and contact lenses
Fitting and adjustment of cardiac device
Fitting and adjustment of orthodontic devices
Fitting and adjustment of other intestinal appliance and device
Fitting and adjustment of gastric lap band
Fitting and adjustment of other gastrointestinal appliance and device
Fitting and adjustment of urinary devices
Fitting and adjustment of orthopedic devices
Fitting and adjustment of wheelchair
Fitting and adjustment of other and unspecified device
Other orthopedic aftercare
Attention to artificial openings
Care involving use of rehabilitation procedures
Care involving speech-language therapy
Orthopedic training, other specified, and unspecified rehabilitation procedure
Orthodontics
Donors
Family disruption due to family member on military deployment
Family disruption due to return of family member from military deployment
Family disruption due to divorce or legal separation
Family disruption due to parent-child estrangement
Family disruption due to child in welfare custody
Family disruption due to child in foster care or in care of non-parental family
member
Family disruption due to death of family member
Family disruption due to other extended absence of family member
Other family disruption
Counseling for marital or partner problems, unspecified
Counseling for victim of spousal and partner abuse
Counseling for perpetrator of spousal and partner abuse
Counseling for parent-child problem
Counseling for victim of child abuse
Counseling for perpetrator of parental child abuse
Counseling for parent-biological child problem
Counseling for parent-adopted child problem
Counseling for parent (guardian)-foster child problem
Other parent-child problems
Problems with aged parents or in-laws
Alcoholism in family
Substance abuse in family
Other specified and unspecified family problems
Personal current military deployment status
Personal history of return from military deployment
Other occupational circumstances or maladjustment
Educational circumstances; other psychological or physical stress, not
elsewhere classified; suicidal ideation
PeaceHealth Laboratories | Medicare Coverage Policies
10
Blood Counts…….con’t
85004, 85007, 85008, 85013, 85014, 85018
NON-COVERED ICD-9 CODES
V62.85
V62.89-V62.9
V65.2
V65.3
V65.40–V65.49
V65.5
V65.8
V65.9
V66.0–V66.9
V67.3
V67.4
V69.3
V71.01–V71.09
V72.0
V72.11-V72.12; V72.19
V72.2
V72.40, V72.41, V72.42
V72.5
V72.60
V72.61
V72.62
V72.63
V72.69
V72.7
V72.9
V76.10–V76.19
V76.2
V76.44
V76.51
V77.1
V81.0-V81.2
85025, 85027, 85032, 85048, 85049
Homicidal ideation
Other psychological or physical stress, not elsewhere classified; and
unspecified psychosocial circumstances
Person feigning illness
Dietary surveillance and counseling
Other counseling, not elsewhere classified
Person with feared complaint in whom no diagnosis was made
Other reasons for seeking consultation
Unspecified reason for consultation
Convalescence and palliative care
Follow-up examination following psychotherapy
Follow-up examination following treatment of healed fracture
Problems related to lifestyle, gambling and betting
Observation and evaluation for suspected conditions not found, mental
Examination of eyes and vision
Encounter for hearing conservation and treatment; other examination of ears
and hearing
Dental examination
Pregnancy examination or test; pregnancy unconfirmed; negative result;
positive result
Radiological examination, not elsewhere classified
Laboratory examination, unspecified
Antibody response examination
Laboratory examination ordered as part of a routine general medical
examination
Pre-procedural laboratory examination
Other laboratory examination
Diagnostic skin and sensitization tests
Unspecified examination
Special screening for malignant neoplasms, breast
Special screening for malignant neoplasms, cervix
Special screening for malignant neoplasms, other sites, prostate
Special screening for malignant neoplasms, Intestine, colon
Special screening for diabetes mellitus
Special screening for cardiovascular diseases
PeaceHealth Laboratories | Medicare Coverage Policies
11
CA 125
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
86304
ICD-9 CODES
158.8
158.9
180.0
182.0
183.0
183.2
183.8
184.8
198.6
198.82
236.0–236.3
338.3
789.39
795.82
795.89
V10.41
V10.42
V10.43-V10.44
TEST NAME
Immunoassay for tumor antigen, quantitative, CA 125
ICD-9 DESCRIPTIONS
Malignant neoplasms, specific parts of peritoneum
Malignant neoplasms, peritoneum, unspecified
Malignant neoplasm, endocervix
Malignant neoplasm of corpus uteri, except isthmus
Malignant neoplasm, ovary
Malignant neoplasm, fallopian tube
Malignant neoplasm, other specified sites of uterine adnexa
Malignant neoplasm, other specified sites of female genital organs
Secondary malignant neoplasm, ovary
Secondary malignancy of genital organs
Neoplasm of uncertain behavior of female genital organs
Neoplasm related pain (acute) (chronic)
Abdominal or pelvic swelling, mass or lump of other specified site
Elevated cancer antigen 125 [CA 125]
Other abnormal tumor markers
Personal history of malignant neoplasm, cervix uteri
Personal history of malignant neoplasm, other parts of the uterus
Personal history of malignant neoplasm of female genital organs
PeaceHealth Laboratories | Medicare Coverage Policies
12
CA 15-3 (27.29)
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
86300
ICD-9 CODES
174.0–174.9
175.0–175.9
198.2
198.81
338.3
795.89
V10.3
TEST NAME
Immunoassay for tumor antigen, quantitative; CA 15–3 (27.29)
ICD-9 DESCRIPTIONS
Breast, primary (female)—malignant neoplasm of female breast
Breast, primary (male)—malignant neoplasm of male breast
Secondary malignant neoplasm (male breast)
Secondary malignant neoplasm (female breast)
Neoplasm related pain (acute) (chronic)
Other abnormal tumor markers
Personal history of malignant neoplasm, breast
PeaceHealth Laboratories | Medicare Coverage Policies
13
CA 19-9
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
86301
ICD-9 CODES
155.1
156.0
156.1
156.2
156.8
156.9
157.0–157.9
197.8
235.3
235.5
338.3
795.89
V10.09
TEST NAME
Immunoassay for tumor antigen, quantitative; CA 19–9
ICD-9 DESCRIPTIONS
Malignant neoplasm, intrahepatic bile ducts
Malignant neoplasm of the gallbladder
Malignant neoplasm, extrahepatic bile ducts
Malignant neoplasm of the Ampulla of Vater
Malignant neoplasm, other specified sites of gallbladder and extrahepatic bile
ducts
Malignant neoplasm, unspecified part of biliary tract
Malignant neoplasm, pancreas
Secondary malignant neoplasm, other digestive organs and spleen
Neoplasm of uncertain behavior, liver and biliary passages
Neoplasm of uncertain behavior, other and unspecified digestive organs
Neoplasm related pain (acute) (chronic)
Other abnormal tumor markers
Other personal history of cancer
PeaceHealth Laboratories | Medicare Coverage Policies
14
Carcinoembryonic Antigen (CEA)
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
82378
ICD-9 CODES
150.0–150.9
151.0–151.9
152.0–154.8
157.0–157.9
159.0
162.0–162.9
174.0–174.9
175.0–175.9
183.0
197.0
197.4
197.5
209.00-209.03
209.10-209.17
209.20-209.27, 209.29
209.70
209.71
209.72
209.73
209.74
209.75
209.79
230.3
230.4
230.7
230.9
235.2
338.3
790.99
795.81
795.89
V10.00
V10.05
V10.06
V10.11
V10.3
V10.43
V67.2
TEST NAME
Carcinoembryonic antigen (CEA)
ICD-9 DESCRIPTIONS
Malignant neoplasm of the esophagus
Malignant neoplasm of stomach
Malignant neoplasm of small intestine, including duodenum, rectum,
rectosigmoid junction and anus
Primary malignancy of pancreas
Malignant neoplasm of intestinal tract, part unspecified
Malignant neoplasm of trachea, bronchus, lung
Malignant neoplasm of female breast
Malignant neoplasm of male breast
Malignant neoplasm of ovary
Secondary malignant neoplasm of neoplasm of lung
Secondary malignant neoplasm of small intestine
Secondary malignant neoplasm of large intestine and rectum
Malignant carcinoid tumors of the small intestine
Malignant carcinoid tumors of the appendix, large intestine, and rectum
Malignant carcinoid tumors of other and unspecified sites
Secondary neuroendocrine tumor, unspecified site
Secondary neuroendocrine tumor of distant lymph nodes
Secondary neuroendocrine tumor of liver
Secondary neuroendocrine tumor of bone
Secondary neuroendocrine tumor of peritoneum
Secondary Merkel cell carcinoma
Secondary neuroendocrine tumor of other sites
Carcinoma in situ of colon
Carcinoma in situ of rectum
Carcinoma in situ of other/unspecified parts of intestine
Carcinoma in situ other and unspecified digestive organs
Neoplasm of uncertain behavior of stomach, intestines, rectum
Neoplasm related pain (acute) (chronic)
Other nonspecific findings on examination of blood
Elevated carcinoembryonic antigen (CEA)
Other abnormal tumor markers
Personal history of malignant neoplasm of gastro-intestinal tract, unspecified
Personal history of malignant neoplasm, large intestine
Personal history of malignant neoplasm, rectum, rectosigmoid junction, anus
Personal history of malignant neoplasm, bronchus, and lung
Personal history of malignant neoplasm, breast
Personal history of malignant neoplasm, ovary
Follow-up examination following chemotherapy
PeaceHealth Laboratories | Medicare Coverage Policies
15
Collagen cross links
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
82523
ICD-9 CODES
242.00–242.91
245.2
246.9
252.00-252.02, 252.08
256.2
256.31-256.39
256.8
256.9
268.9
269.3
627.0
627.1
627.2
627.4
627.8
627.9
731.0
733.00–733.09
733.10–733.19
733.90
805.8
V58.65
V58.69
TEST NAME
Collagen cross links, any method
ICD-9 DESCRIPTIONS
Thyrotoxicosis
Chronic lymphocytic thyroiditis (only if thyrotoxic)
Unspecified disorder of thyroid
Hyperparathyroidism
Postablative ovarian failure
Other ovarian failure
Other ovarian dysfunction
Unspecified ovarian dysfunction
Unspecified vitamin D deficiency
Mineral deficiency, not elsewhere classified
Premenopausal menorrhagia
Postmenopausal bleeding
Symptomatic menopausal or female climacteric states
Symptomatic states associated with artificial menopause
Other specified menopausal and postmenopausal disorders
Unspecified menopausal & postmenopausal disorder
Osteitis deformans without mention of bone tumor (Paget’s disease of bone)
Osteoporosis
Pathological fracture
Disorder of bone and cartilage, unspecified
Fracture of vertebral column without mention of spiral cord injury,
unspecified, closed
Long-term (current) use of steroids
Long-term (current) use of other medications
PeaceHealth Laboratories | Medicare Coverage Policies
16
Cytogenetics Testing
Policy Number: L24295
Policy Type: LCD (Local Coverage Decision)
CPT CODE(S)
88120
88121
88230
88233
88235
88237
88239
88240
88241
88245
88248
88249
88261
88262
88263
88264
88267
88269
88271
88272
88273
88274
88275
88280
88283
88285
88289
88291
88299
TEST NAME
Cytp urine 3-5 probes ea spec
Cytp urine 3-5 probes cmptr
Tissue culture lymphocyte
Tissue culture skin/biopsy
Tissue culture placenta
Tissue culture bone marrow
Tissue culture tumor
Cell cryopreserve/storage
Frozen cell preparation
Chromosome analysis 20-25
Chromosome analysis 50-100
Chromosome analysis 100
Chromosome analysis 5
Chromosome analysis 15-20
Chromosome analysis 45
Chromosome analysis 20-25
Chromosome analys placenta
Chromosome analys amniotic
Cytogenetics DNA probe
Cytogenetics 3-5
Cytogenetics 10-30
Cytogenetics 25-99
Cytogenetics 100-300
Chromosome karyotype study
Chromosome banding study
Chromosome count additional
Chromosome study additional
Cyto/molecular report
Cytogenetic study
PeaceHealth Laboratories | Medicare Coverage Policies
17
ICD-9 CODES
171.9*
188.0
188.1
188.2
188.3
188.4
188.5
188.6
188.7
188.8
189.0
200.00-200.08
200.10-200.18
200.20-200.28
200.80-200.88
201.00-201.08
201.10-201.18
201.20-201.28
201.40-201.48
201.50-201.58
201.60-201.68
201.70-201.78
201.90-201.98
202.00-202.08
202.80-202.88
202.90-202.98
203.00-203.02
203.10-203.12
203.82
204.00-204.02
204.10
204.12
204.22
204.80-204.82
205.00-205.91
206.00-206.02
206.82
206.90-206.91
207.20-207.22
207.82
208.00-208.02
225.2
238.4
238.6
238.71
ICD-9 DESCRIPTIONS
Malignant neoplasm of connective and other soft tissue, site unspecified
Malignant neoplasm of trigone of urinary bladder
Malignant neoplasm of dome of urinary bladder
Malignant neoplasm of lateral wall of urinary bladder
Malignant neoplasm of anterior wall of urinary bladder
Malignant neoplasm of posterior wall of urinary bladder
Malignant neoplasm of bladder neck
Malignant neoplasm of ureteric orifice
Malignant neoplasm of urachus
Malignant neoplasm of other specified sites of bladder
Malignant neoplasm of kidney except pelvis
Reticulosarcoma
Lymphosarcoma
Burkitt's tumor or lymphoma
Other named variants
Hodgkin's paragranuloma
Hodgkin's granuloma
Hodgkin's sarcoma
Lymphocytic-histiocytic predominance
Nodular sclerosis
Mixed cellularity
Lymphocytic depletion
Hodgkin's disease, unspecified
Other malignant neoplasms of lymphoid and histiocytic tissue
Other malignant neoplasms of lymphoid and histiocytic tissue
Other and unspecified malignant neoplasms of lymphoid and histiocytic
tissue
Multiple myeloma
Plasma cell leukemia
Other immunoproliferative neoplasms, in relapse
Lymphoid leukemia
Chronic lymphoid leukemia, without mention of having achieved remission
Chronic lymphoid leukemia, in relapse
Subacute lymphoid leukemia, in relapse
Other lymphoid leukemia
Myeloid leukemia
Acute monocytic leukemia
Other monocytic leukemia, in relapse
Unspecified monocytic leukemia
Megakaryocytic leukemia
Other specified leukemia, in relapse
Leukemia of unspecified cell type
Benign neoplasm of cerebral meninges
Polycythemia vera
Neoplasm of uncertain behavior of plasma cells
Essential thrombocythemia
PeaceHealth Laboratories | Medicare Coverage Policies
18
Cytogenetics…….cont’d
238.72
238.73
238.74
238.75
238.77
238.79
259.0
273.1
273.3
284.01
284.09
284.19
284.2
284.81
284.89
284.9
285.0
285.1
285.21
285.22
285.29
285.8
285.9
287.30-287.39
287.41
287.49
288.01*
288.02
288.1
288.2
288.3
288.4
288.61
288.63
288.64
288.65
288.8
289.6
289.7
289.81-289.89
334.8
388.5
389.10
629.9
88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241,
88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269,
88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289,
88291, 88299
Low grade myelodysplastic syndrome lesions
High grade myelodysplastic syndrome lesions
Myelodysplastic syndrome with 5q deletion
Myelodysplastic syndrome, unspecified
Post-transplant lymphoproliferative disorder (PTLD)
Other lymphatic and hematopoietic tissues
Delay in sexual development and puberty, not elsewhere classified
Monoclonal paraproteinemia
Macroglobulinemia
Constitutional red blood cell aplasia
Other constitutional aplastic anemia
Other pancytopenia
Myelophthisis
Red cell aplasia (acquired) (adult) (with thymoma)
Other specified anemias
Anemia unspecified
Sideroblastic anemia
Acute posthemorrhagic anemia
Anemia in chronic kidney disease
Anemia in neoplastic disease
Anemia of other chronic disease
Other specified anemias
Anemia unspecified
Purpura and other hemorrhagic conditions
Posttransfusion purpura
Other secondary thrombocytopenia
Congenital neutropenia
Cyclic neutropenia
Functional disorders of polymorphonuclear neutrophils
Genetic anomalies of leukocytes
Eosinophilia
Hemophagocytic syndromes
Lymphocytosis (symptomatic)
Monocytosis (symptomatic)
Plasmacytosis
Basophilia
Other specified disease of white blood cells
Familial polycythemia
Methemoglobinemia
Other specified diseases of blood and blood-forming organs
Other spinocerebellar diseases
Disorders of acoustic nerve
Sensorineural hearing loss unspecified
Unspecified disorder of female genital organs
PeaceHealth Laboratories | Medicare Coverage Policies
19
Cytogenetics…….cont’d
630
631.0
632
646.33
655.00-655.23
656.40-656.43
656.50-656.53
656.60-656.63
657.00-657.03
658.00-658.03
659.50-659.53
659.60-659.63
740.0-740.2
742.0-742.8
743.00-743.9
744.00-744.9
745.0-745.9
746.00-746.9
747.0-747.9
748.0-748.9
749.00-749.25
750.0-750.9
751.0-751.9
752.0-752.9
753.0-753.9
754.0-754.89
755.00-755.9
756.0-756.89
757.0
757.1
757.2
757.31-757.39
758.0-758.9
759.83
783.22
783.40
783.41
783.42
783.43
796.5
796.6
V13.61-V13.69
V18.4
88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241,
88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269,
88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289,
88291, 88299
Hydatidiform mole
Inappropriate change in quantitative human chorionic gonadotropin (hcg) in
early pregnancy
Missed abortion
Habitual aborter antepartum condition or complication
Known or suspected fetal abnormaility affecting management of mother
Intrauterine death
Poor fetal growth
Excessive fetal growth
Polyhydramnios
Oligohydramnios
Elderly primigravida
Elderly multigravida
Anencephalus and similar anomalies
Other congenital anomalies of nervous system
Congenital anomalies of eye
Congenital anomalies of ear, face, and neck
Bulbus cordis anomalies and anomalies of cardiac septal closure
Other congenital anomalies of heart
Other congenital anomalies of circulatory system
Congenital anomalies of respiratory system
Cleft palate and cleft lip
Other congenital anomalies of upper alimentary tract
Other congenital anomalies of digestive system
Congenital anomalies of genital organs
Congenital anomalies of urinary system
Certain congenital musculoskeletal deformities
Other congenital anomalies of limbs
Other congenital musculoskeletal anomalies
Hereditary edema of legs
Ichthyosis congenita
Dermatoglyphic anomalies
Other specified anomalies of skin
Chromosomal anomalies
Fragile X syndrome
Underweight
Unspecified lack of normal physiological development
Failure to thrive
Delayed milestones
Short stature
Abnormal finding on antenatal screening
Nonspecific abnormal findings on neonatal screening
Personal history of congenital malformations
Family history of mental retardation
PeaceHealth Laboratories | Medicare Coverage Policies
20
Cytogenetics…….cont’d
V19.5
V49.89*
88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241,
88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269,
88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289,
88291, 88299
Family history of congenital anomalies
Other specified conditions influencing health status
Special Coding:
**171.9
*288.01
*V49.89
Medical record must contain documentation of either alveolar soft part
sarcoma, alveolar rhabdomyosarcoma, clear cell sarcoma, desmoplastic small
sound cell tumor, Ewing sarcoma, myxoid liposarcoma, low grade fibromyxoid
sarcoma, extra skeletal myxoid chondrosarcoma, inflammatory
myofibroblastic tumor, or synovial sarcoma in order to use these diagnosis
codes.
Limited to infantile genetic agranulocytosis only
To be used only when repeat testing is believed to be medically reasonable
and necessary.
PeaceHealth Laboratories | Medicare Coverage Policies
21
Digoxin
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
80162
ICD-9 CODES
242.00–242.91
243
244.0–244.9
245.0–245.9
275.2
275.40–275.49
275.5
276.0
276.1
276.2
276.3
276.4
276.50-276.52
276.61
276.69
276.7
276.8
276.9
293.0
293.1
307.47
339.3
368.16
368.8
368.9
397.9
398.0
398.91
402.01
402.11
402.91
403.00–403.91
404.00–404.93
410.00–410.92
411.0–411.89
413.0–413.9
414.4
422.0–422.99
425.0, 425.11, 425.18
425.2-425.9
TEST NAME
Digoxin (Therapeutic Drug Assay)
ICD-9 DESCRIPTIONS
Thyrotoxicosis with or without goiter
Congenital hypothyroidism
Acquired hypothyroidism
Thyroiditis
Disorders of magnesium metabolism
Disorders of calcium metabolism
Hungry bone syndrome
Hyperosmolality
Hyposmolality
Acidosis
Alkalosis
Mixed acid-base balance disorder
Volume depletion
Transfusion associated circulatory overload
Other fluid overload
Hyperpotassemia
Hypopotassemia
Electrolyte and fluid Disorder (not elsewhere classified)
Acute delirium
Subacute delirium
Other dysfunctions of sleep stages or arousal from sleep
Drug induced headache, not elsewhere classified
Psychophysical visual disturbances
Other specified visual disturbances
Unspecified visual disturbances
Rheumatic diseases of endocardium
Rheumatic Myocarditis
Rheumatic Heart Failure
Hypertensive heart disease, malignant with heart failure
Hypertensive heart disease, benign with heart failure
Hypertensive heart disease, unspecified with heart failure
Hypertensive kidney disease
Hypertensive heart & kidney disease
Acute myocardial infarction
Other acute & subacute forms of ischemic heart disease
Angina pectoris
Coronary atherosclerosis due to calcified coronary lesion
Acute myocarditis
Cardiomyopathy
PeaceHealth Laboratories | Medicare Coverage Policies
22
Digoxin……con’t
426.0–426.9
427.0–427.9
428.0–428.9
429.2
429.4
429.5
429.6
429.71
444.01
444.09
514
573.5
579.9
584.5–584.9
585.1-585.9
586
587
588.0
588.1
588.81
588.89
588.9
780.01
780.02
780.09
780.1
780.2
780.4
780.71–780.79
783.0
784.0
787.01–787.03
787.04
787.91
794.31
799.21
799.22
799.23
799.24
799.25
799.29
972.0
972.1
995.20
995.21
995.24
80162
Conduction disorders
Cardiac dysrhythmias
Heart failure
Cardiovascular disease, unspecified
Heart Disturbances Postcardiac Surgery
Rupture chordae tendinae
Rupture papillary muscle
Acquired cardiac septal defect
Saddle embolus of abdominal aorta
Other arterial embolism and thrombosis of abdominal aorta
Pulmonary congestion & hypostasis
Hepatopulmonary syndrome
Unspecified Intestinal malabsorption
Acute kidney failure
Chronic kidney disease
Renal Failure, unspecified
Renal sclerosis, unspecified
Renal osteodystrophy
Nephrogenic Diabetes Insipidus
Secondary hyperparathyroidism (of renal origin)
Other specified disorders resulting from impaired renal function
Unspecified disorder resulting from impaired renal function
Coma
Transient alteration of awareness
Other ill-defined general symptoms (drowsiness, semicoma, somnolence,
stupor, unconsciousness)
Hallucinations
Syncope & collapse
Dizziness and giddiness
Malaise & fatigue
Anorexia
Headache
Nausea & vomiting
Bilious emesis
Diarrhea
Abnormal electrocardiogram
Nervousness
Irritability
Impulsiveness
Emotional lability
Demoralization and apathy
Other signs and symptoms involving emotional state
Poisoning by cardiac rhythm regulators
Poisoning by cardiotonic glycosides & drugs of similar action
Unspecified adverse effect of drug, medicinal and biological substance
Arthus phenomenon
Failed moderate sedation during procedure
PeaceHealth Laboratories | Medicare Coverage Policies
23
Digoxin……con’t
995.27
995.29
*E942.1
V58.69
Special Coding:
*E942.1
80162
Other drug allergy
Unspecified adverse effect of other drug, medicinal and biologic substance
Adverse effect of cardiotonic glycosides and drugs of similar action
Encounter long term—Medication Use (not elsewhere classified)
Code may not be reported as a stand-alone or first-listed code on the claim
PeaceHealth Laboratories | Medicare Coverage Policies
24
Gamma Glutamyl Transferase (GGT)
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
82977
ICD-9 CODES
003.1
006.0–006.9
014.00–014.86
017.90–017.96
018.90–018.96
020.0–020.9
022.3
027.0
027.1
030.1
032.83
036.1
036.2
038.0, 038.10038.19, 038.2,
038.3, 038.40038.49, 038.8,
038.9
038.12
039.2
040.0
042
054.0
054.5
060.0–060.1
070.0–070.9
072.71
073.0
074.8
075
078.5
079.99
082.0–082.9
084.9
086.1
088.81
091.62
095.3
100.0
TEST NAME
Glutamyltransferase, gamma (GGT)
ICD-9 DESCRIPTIONS
Salmonella septicemia
Amebiasis
Tuberculosis of intestines, peritoneum, and mesenteric glands
Tuberculosis of other specified organs
Miliary tuberculosis, unspecified
Plague
Anthrax septicemia
Listeriosis
Erysipelothrix infection
Tuberculoid leprosy [Type T]
Diphtheritic peritonitis
Meningococcal encephalitis
Meningococcemia
Septicemia
Methicillin resistant Staphylococcus aureus septicemia
Actinomycotic infections, abdominal
Gas gangrene
Human immunodeficiency virus (HIV) disease
Eczema herpeticum
Herpetic septicemia
Yellow fever
Viral hepatitis
Mumps hepatitis
Ornithosis, with pneumonia
Other specified diseases due to Coxsackie virus
Infectious mononucleosis
Cytomegaloviral disease
Unspecified viral infection
Tick-borne rickettsioses, stet
Other pernicious complications of malaria
Chagas disease with organ involvement other than heart
Lyme disease
Secondary syphilitic hepatitis
Syphilis of liver
Leptospirosis icterohemorrhagica
PeaceHealth Laboratories | Medicare Coverage Policies
25
GGT……con’t
112.5
115.00
120.9
121.1
121.3
122.0
122.5
122.8
122.9
130.5
135
150.0–159.9
160.0–165.9
170.0–176.9
179–189.9
200.00–208.92
209.20-209.27,
209.29
209.70
209.71
209.72
209.73
209.74
209.75
209.79
211.5
211.6
211.7
228.04
230.7
230.8
230.9
235.0–238.9
239.0
250.00–250.93
252.00-252.02,
252.08
263.1
263.9
268.0
268.2
269.0
270.2
270.9
271.0
272.0
272.1
82977
Candidiasis, disseminated
Infection by Histoplasma capsulatum without mention of manifestation
Schistosomiasis, unspecified
Clonorchiasis
Fascioliasis
Echinococcus granulosus infection of liver
Echinococcus multilocularis infection of liver
Echinococcosis, unspecified, of liver
Echinococcus, other and unspecified
Hepatitis due to toxoplasmosis
Sarcoidosis
Malignant neoplasm of digestive organs and peritoneum
Malignant neoplasm of respiratory and intrathoracic organs
Malignant neoplasm of bone, connective tissue, skin, and breast
Malignant neoplasm of genitourinary organs
Malignant neoplasm of lymphatic and hematopoietic tissue
Malignant carcinoid tumors of other and unspecified sites
Secondary neuroendocrine tumor, unspecified site
Secondary neuroendocrine tumor of distant lymph nodes
Secondary neuroendocrine tumor of liver
Secondary neuroendocrine tumor of bone
Secondary neuroendocrine tumor of peritoneum
Secondary Merkel cell carcinoma
Secondary neuroendocrine tumor of other sites
Benign neoplasm of liver and biliary passages
Benign neoplasm of pancreas, except islets of Langerhans
Benign neoplasm of islets of Langerhans
Hemangioma of intra-abdominal structures
Carcinoma in situ of other and unspecified parts of intestine
Carcinoma in situ of liver and biliary system
Carcinoma in situ other and unspecified digestive organs
Neoplasms of uncertain behavior
Neoplasm of unspecified nature of digestive system
Diabetes mellitus
Hyperparathyroidism
Malnutrition of mild degree
Unspecified protein-calorie malnutrition
Rickets, active
Osteomalacia, unspecified
Deficiency of vitamin K
Other disturbances of aromatic amino acid metabolism
Unspecified disorder of amino acid metabolism
Glycogenosis
Pure hypercholesterolemia
Pure hyperglyceridemia
PeaceHealth Laboratories | Medicare Coverage Policies
26
GGT……con’t
272.2
272.4
272.7
272.9
273.4
275.01-275.09
275.1
275.2
275.3
275.40–275.49
275.5
277.1
277.30-277.39
277.4
277.6
282.60–282.69
286.6
286.7
289.4
289.52
291.0–291.9
303.00–303.03
303.90–303.93
304.00–304.93
305.00–305.93
357.5
359.21-359.29
452
453.0–453.9
456.0–456.21
555.0–555.9
556.0–556.9
557.0
558.1–558.3,
558.41-558.42,
558.9
560.0–560.2
560.30
560.31
560.32
560.39
560.81-560.89,
560.9
562.01
562.03
562.11
562.13
82977
Mixed hyperlipidemia
Other and unspecified hyperlipidemia
Lipidoses
Unspecified disorder of lipoid metabolism
Alpha-1-antitrypsin deficiency
Disorders of iron metabolism
Disorders of copper metabolism
Disorders of magnesium metabolism
Disorders of phosphorus metabolism
Disorders of calcium metabolism
Hungry bone syndrome
Disorders of porphyrin metabolism
Amyloidosis
Disorders of bilirubin excretion
Other deficiencies of circulating enzymes
Sickle cell anemia
Defibrination syndrome
Acquired coagulation factor deficiency
Hypersplenism
Splenic sequestration
Alcoholic psychoses
Acute alcoholic intoxication
Other and unspecified alcohol dependence
Drug dependence
Non-dependent abuse of drugs
Alcoholic polyneuropathy
Myotonic disorders
Portal vein thrombosis
Other vein embolism and thrombosis
Esophageal varices
Regional enteritis
Ulcerative colitis
Acute vascular insufficiency of intestine
Other noninfectious gastroenteritis and colitis
Intestinal obstruction: intussusceptions, paralytic ileus, volvulus
Impaction of intestine, unspecified
Gallstone ileus
Fecal impaction
Other impaction of intestine
Other and unspecified intestinal obstruction
Diverticulitis of small intestine (without mention of hemorrhage)
Diverticulitis of small intestine with hemorrhage
Diverticulitis of colon (without mention of hemorrhage)
Diverticulitis of colon with hemorrhage
PeaceHealth Laboratories | Medicare Coverage Policies
27
GGT……con’t
567.0–567.29,
567.38-567.9
569.83
569.87
570
571.0–571.9
572.0–572.8
573.0–573.9
574.00–574.91
575.0–575.9
576.0–576.9
581.0–581.9
582.0–582.9
583.0–583.9
584.5–584.9
585.6
586
587
588.0–588.9
590.00–590.9
642.50-642.54
646.70, 646.71,
646.73
782.4
789.1
790.4
790.5
960.0–979.9
980.0–989.89
V42.7
V58.61–V58.64,
V58.69
V67.1
V67.2
V67.51
82977
Peritonitis
Perforation of intestine
Vomiting of fecal matter
Acute and subacute necrosis of liver
Chronic liver disease and cirrhosis
Liver abscess and sequelae of chronic liver disease
Other disorders of liver
Cholelithiasis
Other disorders of gallbladder
Other disorders of biliary tract
Nephrotic syndrome
Chronic glomerulonephritis
Nephritis and nephropathy not specified as acute or chronic
Acute renal failure
End stage renal disease
Renal failure, unspecified
Renal sclerosis, unspecified
Disorders resulting from impaired renal function
Infections of kidney
Severe pre-eclampsia
Liver disorders in pregnancy
Jaundice, unspecified, not of newborn
Hepatomegaly
Nonspecific elevation of levels of transaminase or lactic acid dehydrgenase
Other nonspecific abnormal serum enzyme levels
Poisoning by drugs, medicinal, and biological substances
Toxic effects of substances chiefly nonmedical as to source
Organ replaced by transplant, liver
Long term (current) drug use
Follow-up examination, radiotherapy
Follow-up examination, chemotherapy
Follow-up examination after completed treatment with high-risk medications, not
elsewhere classified
PeaceHealth Laboratories | Medicare Coverage Policies
28
General Health Panel
CPT 80050
Includes the following:
1) 85022/85025 Hemogram/CBC
2) 84443 Thyroid Stimulating Hormone
3) 80053 Comprehensive Metabolic Panel
Documentation supporting
the medical necessity of all
procedures, such as ICD-9
code(s), must be submitted
with each claim. Claims
submitted without such
evidence will be denied as
not medically necessary.
Policy Type: LCD (Local Coverage Policy)
PeaceHealth Laboratories | Medicare Coverage Policies
29
Genetic Testing - New CPT’s as of
01/01/13
Policy Number: L24308
Policy Type: LCD (Local Coverage Decision)
CPT CODE(S)
81201
81202
81203
81211
81212
81213
81214
81215
81216
81217
81270
81275
81292
81293
81294
81295
TEST NAME
APC (Adenomatous polyposis coli) (EG, Familial Adenomatosis Polyposis
[FAP], Attenuated FAP) gene analysis; full gene sequence
APC (Adenomatous polyposis coli) (EG, Familial Adenomatosis Polyposis
[FAP], Attenuated FAP) gene analysis; known familial variants
APC (Adenomatous polyposis coli) (EG, Familial Adenomatosis Polyposis
[FAP], Attenuated FAP) gene analysis; duplication/deletion variants
BRCA1, BRCA2 (Breast cancer 1 & 2) ( EG, hereditary breast & ovarian
cancer) gene analysis; full sequence analysis and common
duplication/deletion variants in BRCA1 (IE, EXON 13 DEL 3.835KB, EXON 13
DUP 6KB, EXON 14-20 DEL 26KB, EXON 22 DEL 510BP, EXON 8-9 DEL 7.1KB)
BRCA1, BRCA2 (Breast cancer 1 & 2) (EG, hereditary breast & ovarian cancer)
gene analysis; 185DELAG, 5385INSC, 6174DELT variants
BRCA1, BRCA2 (Breast cancer 1 & 2) (EG, hereditary breast & ovarian cancer)
gene analysis; uncommon duplication/deletion variants
BRCA1 (Breast cancer 1) (EG, hereditary breast & ovarian cancer) gene
analysis; full sequence analysis & common duplication/deletion variants (IE,
EXON 13 DEL 3.835KB, EXON 13 DUP 6KB, EXON 14-20 DEL 26KB, EXON 22
DEL 510BP, EXON 8-9 DEL 7.1KB)
BRCA1 (Breast cancer 1) (EG, hereditary breast & ovarian cancer) gene
analysis; known familial variant
BRCA2 (Breast cancer 2) (EG, hereditary breast & ovarian cancer) gene
analysis; full sequence analysis
BRCA2 (Breast cancer 2) (EG, hereditary breast & ovarian cancer) gene
analysis; known familial variant
JAK2 (Janus Kinase 2) (EG, Myeloproliferative Disorder) gene analysis,
P.VAL617PHE (V617F) variant
KRAS (V-KI-RAS2 Kirsten Rat Sarcoma Viral Oncogene) (EG, Carcinoma) gene
analysis; variants in Codons 12 & 13
MLH1 (MUTL Homolog 1, colon cancer, non-polyposis type 2) (EG,
hereditary non-polyposis colorectal cancer, lynch syndrome) gene analysis;
full sequence analysis
MLH1 (MUTL Homolog 1, colon cancer, non-polyposis type 2) (EG,
hereditary non-polyposis colorectal cancer, lynch syndrome) gene analysis;
known familial variants
MLH1 (MUTL Homolog 1, colon cancer, non-polyposis type 2) (EG,
hereditary non-polyposis colorectal cancer, lynch syndrome) gene analysis;
duplication/deletion variants
MSH2 (MUTS Homolog 2, colon cancer, non-polyposis type 1) (EG,
hereditary non-polyposis colorectal cancer, lynch syndrome) gene analysis;
full sequence analysis
PeaceHealth Laboratories | Medicare Coverage Policies
30
Genetic Testing - New CPT’s as of
01/01/13
(con’t)
CPT CODE(S)
81296
81297
81298
81299
81300
81317
81318
81319
81381
81401
81403
81405
81406
88363
Policy Number: L24308
Policy Type: LCD (Local Coverage Decision)
TEST NAME
MSH2 (MUTS Homolog 2, colon cancer, non-polyposis type 1) (EG,
hereditary non-polyposis colorectal cancer, lynch syndrome) gene analysis;
known familial variants
MSH2 (MUTS Homolog 2, colon cancer, non-polyposis type 1) (EG,
hereditary non-polyposis colorectal cancer, lynch syndrome) gene analysis;
duplication/deletion variants
MSH6 (MUTS Homolog 6 [E.COLI]) (EG, hereditary non-polyposis colorectal
cancer, lynch syndrome) gene analysis; full sequence analysis
MSH6 (MUTS Homolog 6 [E.COLI]) (EG, hereditary non-polyposis colorectal
cancer, lynch syndrome) gene analysis; known familial variants
MSH6 (MUTS Homolog 6 [E.COLI]) (EG, hereditary non-polyposis colorectal
cancer, lynch syndrome) gene analysis; duplication/deletion variants
PMS2 (Postmeiotic segregation increased 2 [S. Cerevisiae]) (EG, hereditary
non-polyposis colorectal cancer, lynch syndrome) gene analysis; full
sequence analysis
PMS2 (Postmeiotic segregation increased 2 [S. Cerevisiae]) (EG, hereditary
non-polyposis colorectal cancer, lynch syndrome) gene analysis; known
familial variants
PMS2 (Postmeiotic segregation increased 2 [S. Cerevisiae]) (EG, hereditary
non-polyposis colorectal cancer, lynch syndrome) gene analysis;
duplication/deletion variants
HLA class I typing, high resolution (IE, Alleles or Allele groups); one Allele or
Allele group (EG, B*57:01P), each
Molecular pathology procedure, level 2 (EG, 2-10 SNPS, 1 methylated
variant, or 1 somatic variant [typically using non-sequencing target variant
analysis], or detection of a dynamic mutation disorder/triplet repeat)
Molecular pathology procedure, level 4 (EG, analysis of single exon by DNA
sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or
more independent reactions, mutation scanning or duplication/deletion
variants of 2-5 exons)
Molecular pathology procedure, level 6 (EG, analysis of 6-10 exons by DNA
sequence analysis, mutation scanning or duplication/deletion variants of 1125 exons)
Molecular pathology procedure, level 7 (EG, analysis of 11-25 exons by DNA
sequence analysis, mutation scanning or duplication/deletion variants of 2650 exons, cytogenomic array analysis for neoplasia)
Examination and selection of retrieved archival (IE, previously diagnosed)
tissue(s) for molecular analysis (EG, KRAS mutational analysis)
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Genetic Testing - Retired CPT’s as of
12/31/12
Policy Number: L24308
Policy Type: LCD (Local Coverage Decision)
CPT CODE(S)
83890
TEST NAME
Molecular diagnostics; molecular isolation or extraction
83891
Molecular diagnostics; isolation or extraction of highly purified nucleic acid
83892
83893
Molecular diagnostics; enzymatic digestion
Molecular diagnostics; dot/slot blot production
Molecular diagnostics; separation by gel electrophoresis (eg, agarose,
polyacrylamide)
Molecular diagnostics; nucleic acid probe, each
Molecular diagnostics; amplification, target, each nucleic acid sequence
Molecular diagnostics; amplification, target, multiplex, first 2 nucleic acid
sequences
Molecular diagnostics; mutation identification by sequencing, single
segment, each segment
Molecular diagnostics; separation and identification by high resolution
technique (eg, capillary electrophoresis), each nucleic acid preparation
Molecular diagnostics; interpretation and report
Examination and selection of retrieved archival (i.e. previously diagnosed)
tissue(s) for molecular analysis (e.g. Kras Mutational Analysis)
83894
83896
83898
83900
83904
83909
83912
88363
The following diagnosis codes billed with CPT codes 81211, 81212, 81213,
81214, 81215, 81216, and 81217 meet coverage criteria for BRCA1 and
BRCA2 gene mutation testing:
ICD-9 CODES
158.0
158.8
174.0
174.1
174.2
174.3
174.4
174.5
174.6
174.8
174.9
175.0
175.9
183.0
183.2
233.0
V10.3
V10.43
ICD-9 DESCRIPTIONS
Malignant neoplasm of retroperitoneum
Malignant neoplasm of specified parts of peritoneum
Malignant neoplasm of nipple and areola of female breast
Malignant neoplasm of central portion of female breast
Malignant neoplasm of upper-inner quadrant of female breast
Malignant neoplasm of lower-inner quadrant of female breast
Malignant neoplasm of upper-outer quadrant of female breast
Malignant neoplasm of lower-outer quadrant of female breast
Malignant neoplasm of axillary tail of female breast
Malignant neoplasm of other specified sites of female breast
Malignant neoplasm of breast (female) unspecified site
Malignant neoplasm of nipple and areola of male breast
Malignant neoplasm of other and unspecified sites of male breast
Malignant neoplasm of ovary
Malignant neoplasm of fallopian tube
Carcinoma in situ of breast
Personal history of malignant neoplasm of breast
Personal history of malignant neoplasm of ovary
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The following diagnosis codes billed with CPT codes 81201, 81202, 81203,
81275, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317,
81318, 81319, 81401, 81403, 81405, 81406, and 88363 meet coverage criteria
for hereditary colorectal cancer (HNPCC) including endometrial and/or ovarian
cancer when the latter two are reasonably considered part of the Lynch
syndrome, Familial Adenomatous Polyposis (FAP) testing as well as for KRAS
testing, when such testing is used to determine suitability of the use of either
Erbitux or Panitumumab within the limitations noted above:
ICD-9 CODES
153.0
153.1
153.2
153.3
153.4
153.5
153.6
153.7
153.8
153.9
154.0
154.1
154.2
154.3
154.8
179
182.8
183.0
183.2
197.5
V10.05
V10.06
V10.42
V12.72*
ICD-9 DESCRIPTIONS
Malignant neoplasm of hepatic flexure
Malignant neoplasm of transverse colon
Malignant neoplasm of descending colon
Malignant neoplasm of sigmoid colon
Malignant neoplasm of cecum
Malignant neoplasm of appendix vermiformis
Malignant neoplasm of ascending colon
Malignant neoplasm of splenic flexure
Malignant neoplasm of other specified sites of large intestine
Malignant neoplasm of colon unspecified site
Malignant neoplasm of rectosigmoid junction
Malignant neoplasm of rectum
Malignant neoplasm of anal canal
Malignant neoplasm of anus unspecified site
Malignant neoplasm of other sites of rectum rectosigmoid junction and anus
Malignant neoplasm of uterus-part uns
Malignant neoplasm of other specified sites of body of uterus
Malignant neoplasm of ovary
Malignant neoplasm of fallopian tube
Secondary malignant neoplasm of large intestine and rectum
Personal history of malignant neoplasm of large intestine
Personal history of malignant neoplasm of rectum, rectosigmoid junction &
anus
Personal history of malignant neoplasm of other parts of uterus
Personal history of colonic polyps
*V12.72 should be used to denote any of the polyposis conditions as described under the Indications and
Limitations above.
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The following diagnosis codes when billed with CPT codes 81270 and
81403 meet coverage criteria for JAK2 testing:
ICD-9 CODES
204.00
204.10
204.11
204.12
205.00
205.10
238.4
238.71
238.75
238.76
238.79
287.5
288.50
288.51
288.59
288.61
288.69
288.8
453.0
789.2
ICD-9 DESCRIPTIONS
Acute lymphoid leukemia, without mention of having achieved remission
Chronic lymphoid leukemia, without mention of having achieved remission
Lymphoid leukemia, chronic, in remission
Chronic lymphoid leukemia, in relapse
Acute myeloid leukemia, without mention of having achieved remission
Chronic myeloid leukemia, without mention of having achieved remission
Polycythemia vera
Essential thrombocythemia
Myelodysplastic syndrome, unspecified
Myelofibrosis with myeloid metaplasia
Other lymphatic and hematopoietic tissues
Thrombocytopenia unspecified
Leukocytopenia, unspecified
Lymphocytopenia
Other decreased white blood cell count
Lymphocytosis (symptomatic)
Other elevated white blood cell count
Other specified disease of white blood cells
Budd-Chiari Syndrome
Splenomegaly
Multiple CPT codes exist for the various molecular tests for lymphoma.
The appropriate code should be selected from the most current CPT
manual. The following diagnosis codes meet coverage criteria as
indications for molecular testing of lymphoma, so long as
documentation of medical necessity for the specific test in question is
present in the medical record, as noted elsewhere in this LCD:
ICD-9 CODES
200.40
ICD-9 DESCRIPTIONS
Mantle cell lymphoma, unspecified site, extranodal and solid organ sites
200.41
Mantle cell lymphoma, lymph nodes of head, face, and neck
200.42
Mantle cell lymphoma, intrathoracic lymph nodes
200.43
Mantle cell lymphoma, intra-abdominal lymph nodes
200.44
Mantle cell lymphoma, lymph nodes of axilla and upper limb
200.45
Mantle cell lymphoma, lymph nodes of inguinal region and lower limb
200.46
Mantle cell lymphoma, intrapelvic lymph nodes
200.47
Mantle cell lymphoma, spleen
200.48
Mantle cell lymphoma, lymph nodes of multiple sites
200.70
Large cell lymphoma, unspecified site, extranodal and solid organ sites
200.71
Large cell lymphoma, lymph nodes of head, face, and neck
200.72
Large cell lymphoma, intrathoracic lymph nodes
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ICD-9 CODES
200.73
ICD-9 DESCRIPTIONS
Large cell lymphoma, intra-abdominal lymph nodes
200.74
Large cell lymphoma, lymph nodes of axilla and upper limb
200.75
Large cell lymphoma, lymph nodes of inguinal region and lower limb
200.76
Large cell lymphoma, intrapelvic lymph nodes
200.77
Large cell lymphoma, spleen
200.78
Large cell lymphoma, lymph nodes of multiple sites
202.00
Nodular lymphoma unspecified site
202.01
Nodular lymphoma involving lymph nodes of head face and neck
202.02
Nodular lymphoma involving intrathoracic lymph nodes
202.03
Nodular lymphoma involving intra-abdominal lymph nodes
202.04
Nodular lymphoma involving lymph nodes of axilla and upper limb
202.05
Nodular lymphoma involving lymph nodes of inguinal region and lower limb
202.06
Nodular lymphoma involving intrapelvic lymph nodes
202.07
Nodular lymphoma involving spleen
202.08
Nodular lymphoma involving lymph nodes of multiple sites
The following diagnosis codes when billed with CPT code 81403 meet
coverage criteria as indications for testing for BCR/ABL fusion gene so
long as documentation of medical necessity for the specific test in
question is present in the medical record, as noted elsewhere in this
LCD:
ICD-9 CODES
204.00
ICD-9 DESCRIPTIONS
Acute lymphoid leukemia, without mention of having achieved remission
204.01
Lymphoid leukemia acute in remission
204.02
Acute lymphoid leukemia, in relapse
204.10
Chronic lymphoid leukemia, without mention of having achieved remission
204.11
Lymphoid leukemia chronic in remission
204.12
Chronic lymphoid leukemia, in relapse
204.20
Sub-acute lymphoid leukemia, without mention of having achieved remission
204.21
Lymphoid leukemia sub-acute in remission
204.22
Sub-acute lymphoid leukemia, in relapse
204.80
Other lymphoid leukemia, without mention of having achieved remission
204.81
Other lymphoid leukemia in remission
204.82
Other lymphoid leukemia, in relapse
204.90
Unspecified lymphoid leukemia, without mention of having achieved remission
204.91
Unspecified lymphoid leukemia in remission
204.92
Unspecified lymphoid leukemia, in relapse
205.00
Acute myeloid leukemia, without mention of having achieved remission
205.01
Myeloid leukemia acute in remission
205.02
Acute myeloid leukemia, in relapse
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ICD-9 CODES
205.10
ICD-9 DESCRIPTIONS
Chronic myeloid leukemia, without mention of having achieved remission
205.11
Myeloid leukemia chronic in remission
205.12
Chronic myeloid leukemia, in relapse
205.20
Sub-acute myeloid leukemia, without mention of having achieved remission
205.21
Myeloid leukemia sub-acute in remission
205.22
Sub-acute myeloid leukemia, in relapse
205.30
Myeloid sarcoma, without mention of having achieved remission
205.31
Myeloid sarcoma in remission
205.32
Myeloid sarcoma, in relapse
205.80
Other myeloid leukemia, without mention of having achieved remission
205.81
Other myeloid leukemia in remission
205.82
Other myeloid leukemia, in relapse
205.90
Unspecified myeloid leukemia, without mention of having achieved remission
205.91
Unspecified myeloid leukemia in remission
205.92
Unspecified myeloid leukemia, in relapse
206.00
Acute monocytic leukemia, without mention of having achieved remission
206.01
Monocytic leukemia acute in remission
206.02
Acute monocytic leukemia, in relapse
206.10
Chronic monocytic leukemia, without mention of having achieved remission
206.11
Monocytic leukemia chronic in remission
206.12
Chronic monocytic leukemia, in relapse
206.20
Sub-acute monocytic leukemia, without mention of having achieved remission
206.21
Monocytic leukemia sub-acute in remission
206.22
Sub-acute monocytic leukemia, in relapse
206.80
Other monocytic leukemia, without mention of having achieved remission
206.81
Other monocytic leukemia in remission
206.82
Other monocytic leukemia, in relapse
206.90
Unspecified monocytic leukemia, without mention of having achieved remission
206.91
Unspecified monocytic leukemia in remission
206.92
Unspecified monocytic leukemia, in relapse
208.00
Acute leukemia of unspecified cell type, without mention of having achieved remission
208.01
Leukemia of unspecified cell type acute in remission
208.02
Acute leukemia of unspecified cell type, in relapse
208.10
Chronic leukemia of unspecified cell type, without mention of having achieved
remission
208.11
Leukemia of unspecified cell type chronic in remission
208.12
Chronic leukemia of unspecified cell type, in relapse
208.20
Sub-acute leukemia of unspecified cell type, without mention of having achieved
remission
208.21
Leukemia of unspecified cell type sub-acute in remission
208.22
Sub-acute leukemia of unspecified cell type, in relapse
208.80
Other leukemia of unspecified cell type, without mention of having achieved remission
208.81
Other leukemia of unspecified cell type in remission
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ICD-9 CODES
208.82
ICD-9 DESCRIPTIONS
Other leukemia of unspecified cell type, in relapse
208.90
Unspecified leukemia, without mention of having achieved remission
208.91
Unspecified leukemia in remission
208.92
Unspecified leukemia, in relapse
288.61
Lymphocytosis (symptomatic)
288.69
Other elevated white blood cell count
288.8
Other specified disease of white blood cells
789.2
Splenomegaly
The following diagnosis codes when billed with CPT code 81381 meet
coverage criteria as indications for HLA-B*5701 testing prior to
initiating abacavir therapy in patients with either Human
Immunodeficiency Virus (HIV) disease or Asymptomatic Human
Immunodeficiency virus (HIV) infection.
ICD-9 CODES
042
ICD-9 DESCRIPTIONS
Human immunodeficiency virus (HIV) disease
V08
Asymptomatic human immunodeficiency virus (HIV) infection status
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Glucose Testing
Policy Type: NCD (National Coverage
Decision)
CPT CODE(S)
82947
82948
82962
ICD-9 CODES
011.00–011.96
038.0–038.9
112.1
112.3
118
157.4
158.0
211.7
242.00–242.91
249.00-249.91
250.00–250.93
251.0–251.9
253.0–253.9
255.0
263.0–263.9
271.0–271.9
272.0–272–4
275.01-275.09
276.0–276.9
278.3
293.0
294.9
298.9
300.9
310.1
331.83
337.9
345.10–345.11
348.31
355.9
356.9
357.9
362.10
362.18
362.29
TEST NAME
Glucose; quantitative, blood (except reagent strip)
Glucose; blood, reagent strip
Glucose, blood by glucose monitoring device(s) cleared by the FDA
specifically for home use
ICD-9 DESCRIPTIONS
Tuberculosis
Septicemia
Recurrent vaginal candidiasis
Interdigital candidiasis
Opportunistic mycoses
Malignant neoplasm of Islets of Langerhans
Malignant neoplasm of retroperitoneum
Benign neoplasm of Islets of Langerhans
Thyrotoxicosis
Secondary diabetes mellitus
Diabetes mellitus
Disorders of pancreatic internal secretion
Disorders of the pituitary gland
Cushing syndrome
Malnutrition
Disorders of carbohydrate transport and metabolism
Disorders of lipoid metabolism
Hemochromotosis
Disorders of fluid, electrolyte and acid-base balance
Hypercarotinemia
Acute delirium
Unspecified organic brain syndrome
Unspecified psychosis
Unspecified neurotic disorder
Organic personality syndrome
Mild cognitive impairment, so stated
Autonomic nervous system neuropathy
Generalized convulsive epilepsy
Metabolic encephalopathy
Neuropathy, not otherwise specified
Unspecified hereditary and idiopathic peripheral neuropathy
Unspecified inflammatory and toxic neuropathy
Background retinopathy
Retinal vasculitis
Nondiabetic proliferative retinopathy
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Glucose Testing…cont’d
362.50–362.57
362.60–362.66
362.81–362.89
362.9
365.04
365.32
366.00–366.09
366.10–366.19
367.1
368.8
373.00
377.24
377.9
378.50–378.55
379.45
410.00–410.92
414.00–414.19
414.3
414.4
425.9
440.23
440.24
440.9
458.0
462
466.0
480.0–486
490
491.0–491.9
527.7
528.00
528.09
535.50–535.51
536.8
571.8
572.0–572.8
574.50–574.51
575.0–575.12
576.1
577.0
577.1
577.8
590.00–590.9
595.9
596.4
596.53
82947, 82948, 82962
Degeneration of macular posterior pole
Peripherial retinal degeneration
Other retinal disorders
Unspecified retinal disorders
Borderline glaucoma, ocular hypertension
Corticosteriod-induced glaucoma residual
Presenile cataract
Senile cataract
Acute myopia
Other specified visual disturbance
Blepharitis
Pseudopapilledema
Autonomic nervous system neuropathy
Paralytic strabiamus
Argyll-Robertson pupils
Acute myocardial infarctions
Coronary atherosclerosis and aneurysm of heart
Coronary atherosclerosis due to lipid rich plaque
Coronary atherosclerosis due to calcified coronary lesion
Secondary cardiomyopathy, unspecified
Arteriosclerosis of extremities with ulceration
Arteriosclerosis of extremities with gangrene
Arteriosclerosis, not otherwise specified
Postural hypotension
Acute pharyngitis
Acute bronchitis
Pneumonia
Recurrent bronchitis, not specified as acute or chronic
Chronic bronchitis
Disturbance of salivory secretion (drymouth)
Stomatitis & mucositis, unspecified
Other stomatitis & mucositis (ulcerative)
Gastritis
Dyspepsia
Other chronic nonalcoholic liver disease
Liver abscess and sequelae of chronic liver disease
Choledocholitiasis
Cholecystitis
Cholangitis
Acute pancreatitis
Chronic pancreatitis
Pancreatic multiple calculi
Infections of the kidney
Recurrent cystitis
Bladder atony
Bladder paresis
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Glucose Testing…cont’d
599.0
607.84
608.89
616.10
626.0
626.4
628.9
648.00
82947, 82948, 82962
Urinary tract infection, recurrent
Impotence of organic origin
Other disorders male genital organs
Vulvovaginitis
Amenorrhea
Irregular menses
Infertility—female
Diabetes mellitus complicating pregnancy, Childbirth or the puerperium,
unspecified as to episode of care or not applicable
648.03
Diabetes mellitus complicating pregnancy, Childbirth or the puerperium,
antipartum condition or complication
648.04
Diabetes mellitus complicating pregnancy, Childbirth or the puerperium,
postpartum condition or complication
648.80
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, unspecified as to episode of care or not applicable
648.83
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, antipartum condition or complication
648.84
649.20-649.24
656.60–656.63
657.00–657.03
680.0–680.9
686.00–686.9
698.0
698.1
704.1
705.0
707.00–707.9
709.3
729.1
730.07
730.17
730.27
780.01
780.02
780.09
780.2
780.31
780.32
780.33
780.39
780.4
780.71–780.79
780.8
781.0
782.0
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, postpartum condition or complication
Bariatric surgery status complicating pregnancy
Fetal problems affecting management of mother—large for-date of fetus
Polyhydramnios
Carbuncle and furuncle
Infections of skin and subcutaneous tissue
Pruritis ani
Pruritis of genital organs
Hirsutism
Anhidrosis
Chronic ulcer of skin
Degenerative skin disorders
Myalgia
Acute osteomyelitis of ankle and foot
Chronic osteomyelitis of ankle and foot
Unspecified osteomyelitis of ankle and foot
Coma
Transient alteration of awareness
Alteration of consciousness, other
Syncope and collapse
Febrile convulsions
Complex febrile convulsions
Post traumatic seizures
Seizures, not otherwise specified
Dizziness and giddiness
Malaise and fatigue
Hyperhidrosis
Abnormal involuntary movements
Loss of vibratory sensation
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Glucose Testing…cont’d
783.1
783.21
783.5
783.6
785.0
785.4
786.01
786.09
786.50
787.60-787.63
787.91
788.41–788.43
789.1
790.21
790.22
790.29
790.6
791.0
791.5
796.1
799.4
V23.0–V23.9
V58.63
V58.64
V58.65
V58.67
V58.69
V67.2
V67.51
V77.1 Covered for
procedure code 82947
only
82947, 82948, 82962
Abnormal weight gain
Abnormal loss of weight
Polydipsia
Polyphagia
Tachycardia
Gangrene
Hyperventilation
Dyspnea,
Chest pain, unspecified
Fecal incontinence
Diarrhea
Frequency of urination and polyuria
Hepatomegaly
Impaired fasting glucose
Impaired glucose tolerance test (oral)
Other abnormal glucose
Other abnormal blood chemistry (hyperglycemia)
Proteinuria
Glycosuria
Abnormal reflex
Cachexia
Supervision of high risk pregnancy
Long-term (current) use of antiplatelets/antithrombotics
Long-term (current) use of non-steroidal anti-inflammatories (NSAID)
Long-term (current) use of steroids
Long-term (current) use of insulin
Long term current use of other medication
Follow-up examination, following chemotherapy
Follow up examination with high-risk medication not elsewhere classified
Screening for diabetes mellitus
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Glycated Protein/Glycohemoglobin
Policy Type: NCD (National
Coverage Decision)
CPT CODE(S)
82985
83036
ICD-9 CODES
211.7
249.00-249.01
249.10-249.11
249.20-249.21
249.30-249.31
249.40-249.41
249.50-249.51
249.60-249.61
249.70-249.71
249.80-249.81
249.90-249.91
250.00–250.93
251.0
251.1
251.2
251.3
251.4
251.8
251.9
258.0–258.9
271.4
275.01-275.09
577.1
579.3
648.00
TEST NAME
Glycated protein
Hemoglobin; glycated
ICD-9 DESCRIPTIONS
Benign neoplasm of islets of Langerhans
Secondary diabetes mellitus without mention of complication
Secondary diabetes mellitus with ketoacidosis
Secondary diabetes mellitus with hyperosmolarity
Secondary diabetes mellitus with other coma
Secondary diabetes mellitus with renal manifestations
Secondary diabetes mellitus with ophthalmic manifestations
Secondary diabetes mellitus with neurological manifestations
Secondary diabetes mellitus with peripheral circulatory disorders
Secondary diabetes mellitus with other specified manifestations
Secondary diabetes mellitus with unspecified complication
Diabetes mellitus & various related codes
Hypoglycemic coma
Other specified hypoglycemia
Hypoglycemia unspecified
Post-surgical hypoinsulinemia
Abnormality of secretion of glucagon
Other specified disorders of pancreatic internal secretion
Unspecified disorder of pancreatic internal secretion
Polyglandular dysfunction
Renal glycosuria
Hemochromatosis
Chronic pancreatitis
Other and unspecified postsurgical nonabsorption
Diabetes mellitus complicating pregnancy, Childbirth or the puerperium,
unspecified as to episode of care or not applicable
648.03
Diabetes mellitus complicating pregnancy, Childbirth or the puerperium,
antepartum condition or complication
648.04
Diabetes mellitus complicating pregnancy, Childbirth or the puerperium,
postpartum condition or complication
648.80
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, unspecified as to episode of care or not applicable
648.83
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, antepartum condition or complication
648.84
790.21
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, postpartum condition or complication
Impaired fasting glucose
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Glycated Protein/Glycohemoglobin………con’t
790.22
790.29
790.6
962.3
V12.21
V12.29
V58.67
V58.69
82985, 83036
Impaired glucose tolerance test (oral)
Other abnormal glucose
Other abnormal blood chemistry (hyperglycemia)
Poisoning by insulin and antidiabetic agents
Personal history of gestational diabetes
Personal history of other endocrine, metabolic, and immunity disorders
Long-term (current) use of insulin
Long-term use of other medication
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Gonadotropin (hCG)
Policy Type: NCD (National Coverage
Decision)
CPT CODE(S)
84702
ICD-9 CODES
158.0
158.8
164.2
164.3
164.8
164.9
181
183.0
183.8
186.0
186.9
194.4
197.1
197.6
198.6
198.82
236.1
338.3
623.8
625.9
630
631.0
631.8
632
633.90-633.91
634.00–634.02
640.00–640.03
642.30–642.34
642.40–642.74
642.90–642.94
795.89
V10.09
V10.29
V10.43
TEST NAME
Gonodotropin, chorionic (hCG); quantitative
ICD-9 DESCRIPTIONS
Malignant neoplasm of retroperitoneum
Malignant neoplasm of specified parts of peritoneum
Malignant neoplasm of anterior mediastinum
Malignant neoplasm of posterior mediastinum
Malignant neoplasm, other (includes malignant neoplasm of contiguous
overlapping sites of thymus, heart, and mediastinum whose point of origin cannot
be determined
Malignant neoplasm of mediastinum, part unspecified
Malignant neoplasm of placenta
Malignant neoplasm of ovary
Other specified sites of uterine adnexas
Malignant neoplasm of undescended testes
Malignant neoplasm of other and unspecified testis
Malignant neoplasm of pineal gland
Secondary malignant neoplasm of mediastinum
Secondary malignant neoplasm of retroperitoneum and peritoneum
Secondary malignant neoplasm of ovary
Secondary malignant neoplasm of other genital organs
Neoplasm of uncertain behavior, placenta
Neoplasm related pain (acute) (chronic)
Vaginal bleeding
Pelvic pain
Hydatidiform mole
Inappropriate change in quantitative human chorionic gonadotropin (hCG) in
early pregnancy
Other abnormal products of conception
Missed abortion
Ectopic pregnancy
Spontaneous abortion, complicated by genital tract and pelvic infection
Threatened abortion
Transient hypertension of pregnancy
Pre-eclampsia or eclampsia
Unspecified hypertension complicating pregnancy, childbirth, or the proerperium
Other abnormal tumor markers
Personal history of malignant neoplasm, other gastrointestinal sites
Personal history of malignant neoplasm of other respiratory and intrathoracic
organs
Personal history of malignant neoplasm, ovary
PeaceHealth Laboratories | Medicare Coverage Policies
44
ICD-9 CODES
V10.47
V22.0–V22.1
ICD-9 DESCRIPTIONS
Personal history of malignant neoplasm, testis
Pregnancy
PeaceHealth Laboratories | Medicare Coverage Policies
45
Hepatitis Panel
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
80074
ICD-9 CODES
070.0–070.9
456.0–456.21
570
571.5
572.0–572.8
573.3
573.5
780.31
780.32
780.33
780.71
780.72
780.79
782.4
783.0–783.6
787.01–787.03
787.04
789.00–789.09
789.1
789.61
789.7
790.4
794.8
996.82
V72.85
TEST NAME
Acute Hepatitis Panel
ICD-9 DESCRIPTIONS
Viral hepatitis
Esophageal varices with or without mention of bleeding
Acute and subacute necrosis of liver
Cirrhosis of liver without mention of alcohol
Liver abscess and sequelae of chronic liver disease
Hepatitis, unspecified
Hepatopulmonary syndrome
Febrile convulsions
Complex febrile convulsions
Post traumatic seizures
Chronic fatigue syndrome
Functional quadiplegia
Other malaise and fatigue
Jaundice, unspecified, not of newborn
Symptoms concerning nutrition, metabolism, and development
Nausea and vomiting
Bilious emesis
Abdominal pain
Hepatomegaly
Localized abdominal tenderness (RUQ)
Colic
Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase (LDH)
Nonspecific abnormal results of function
Complications of transplanted organ, liver
Liver transplant recipient evaluation
PeaceHealth Laboratories | Medicare Coverage Policies
46
HIV testing: diagnosis
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
86689
86701
86702
86703
87390
87391
87534
87535
87537
87538
ICD-9 CODES
003.1
007.2
007.4
007.8
010.00–010.96
011.00–011.96
012.00–012.86
013.00–013.96
014.00–014.86
015.00–015.96
016.00–016.96
017.00–017.96
018.00–018.96
027.0
031.0–031.9
038.2
038.43
039.0–039.9
041.7
042
046.3
049.0–049.9
052.0–052.8
TEST NAME
Qualitative or semi-quantitative immunoassays performed by multiple step
methods; HTLV or HIV antibody, confirmatory test (for example, Western
Blot)
Antibody; HIV–1
Antibody; HIV–2
Antibody; HIV-1 and HIV-2, single assay
Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semi-quantitative, multiple step; HIV--1
Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semi-quantitative, multiple step: HIV--2
Infectious agent detection by nucleic acid (DNA or RNA); HIV–1, direct probe
technique
Infectious agent detection by nucleic acid (DNA or RNA); HIV–1, direct probe
technique HIV–1, amplified probe technique
Infectious agent detection by nucleic acid (DNA or RNA); HIV–2, direct probe
technique
Infectious agent detection by nucleic acid (DNA or RNA); HIV–2, amplified
probe technique
ICD-9 DESCRIPTIONS
Salmonella septicemia
Coccidiosis (Isoporiasis)
Cryptosporidiosis
Other specified protozoal intestinal diseases
Primary tuberculous infection
Pulmonary tuberculosis
Other respiratory tuberculosis
Tuberculosis of meninges and central nervous system
Tuberculosis of intestines, peritoneum and mesenteric glands
Tuberculosis of bones and joints
Tuberculosis of genitourinary system
Tuberculosis of other organs
Miliary tuberculosis
Listeriosis
Diseases due to other mycobacteria
Pneumococcal septicemia
Septicemia (Pseudomonas)
Actinomycotic infections (includes Nocardia)
Pseudomonas infection
HIV disease (Acute retroviral syndrome, AIDS-related complex)
Progressive multifocal leukoencephalopathy
Other non-arthropod-borne viral diseases of central nervous system
Chickenpox (with complication)
PeaceHealth Laboratories | Medicare Coverage Policies
47
HIV Testing: diagnosis….con’t
053.0–053.9
054.0–054.9
055.0–055.8
070.20–070.23
070.30–070.33
070.41
070.42
070.44
070.49
070.51
070.52
070.54
070.59
070.6
070.70
070.71
070.9
078.0
078.10–078.19
078.3
078.5
078.88
079.50
079.51
079.52
079.53
079.59
079.83
079.88
079.98
085.0–085.9
088.0
090.0–090.9
091.0–091.9
092.0–092.9
093.0–093.9
094.0–094.9
095.0–095.9
096
097.0–097.9
098.0–098.89
099.0
099.1
099.2
099.3
099.40–099.49
86689, 86701, 86702, 86703, 87390, 87391,
87534, 87535, 87537, 87538
Herpes zoster
Herpes simplex
Measles (with complication)
Viral hepatitis B with hepatic coma
Viral hepatitis B without mention of hepatic coma
Acute or unspecified hepatitis C with hepatic coma
Hepatitis delta without mention of active hepatitis B disease with hepatic coma
Chronic hepatitis C with hepatic coma
Other specified viral hepatitis with hepatic coma
Acute or unspecified hepatitis C without hepatic coma
Hepatitis delta without mention of active hepatitis B disease without hepatic coma
Chronic hepatitis C without hepatic coma
Other specified viral hepatitis without hepatic coma
Unspecified viral hepatitis with hepatic coma
Unspecified viral hepatitis C without hepatic coma
Unspecified viral hepatitis C with hepatic coma
Unspecified viral hepatitis without hepatic coma
Molluscum contagiosum
Viral warts
Cat-scratch disease
Cytomegaloviral disease
Other specified diseases due to Chlamydiae
Retrovirus unspecified
HTLV–I
HTLV–II
HTLV–III
Other specified Retrovirus
Parvovirus B19
Other specified chlamydial infection
Unspecified chlamydial infection
Leishmaniasis
Bartonellosis
Congenital syphilis
Early syphilis symptomatic
Early syphilis, latent
Cardiovascular syphilis
Neurosyphilis
Other forms of late syphilis, with symptoms
Late syphilis, latent
Other and unspecified syphilis
Gonococcal infections
Chancroid
Lymphogranuloma venereum
Granuloma inguinale
Reiter’s disease
Other nongonococcal urethritis
PeaceHealth Laboratories | Medicare Coverage Policies
48
86689, 86701, 86702, 86703, 87390, 87391,
87534, 87535, 87537, 87538
Other venereal diseases due to Chlamydia trachomatis
Other specified venereal disease
Venereal disease unspecified
Dermatophytosis of nail
Pityriasis versicolor
Candidiasis
Coccidioidomycosis
Histoplasmosis
Blastomycotic infection
Aspergillosis
Cryptococcosis
Opportunistic mycoses
Strongyloidiasis
Toxoplasmosis
Trichomonal vulvovaginitis
Phthirus pubis
Scabies
Specific infections by free living amebae
Pneumocystosis
Other specified infectious and parasitic disease (for example, microsporidiosis)
Kaposi’s sarcoma
Malignant neoplasm of cervix uteri
Burkitt’s tumor or lymphoma
Lymphosarcoma, other named variants
Hodgkin’s disease
Malnutrition of moderate degree
Malnutrition of mild degree
Unspecified protein-calorie malnutrition
Iron deficiency anemias
Anemia, unspecified
Primary thrombocytopenia
Neutropenia
Hemophagocytic syndromes
Decreased white blood cell count
Increased white blood cell count
Other specified disease of white blood cells
Neutropenic splenomegaly
Other specified organic brain syndromes (chronic)
Organic personality syndrome
Chronic meningitis
Other frontotemporal dementia
Mild cognitive impairment, so stated
Unspecified disease of spinal cord
Encephalopathy, unspecified
Other encephalopathy
Mononeuritis of upper limbs and mononeuritis multiplex
HIV Testing: diagnosis….con’t
099.50–099.59
099.8
099.9
110.1
111.0
112.0–112.9
114.0–114.9
115.00–115.99
116.0–116.2
117.3
117.5
118
127.2
130.0–130.9
131.01
132.2
133.0
136.21-136.29
136.3
136.8
176.0–176.9
180.0–180.9
200.20–200.28
200.80–200.88
201.00–201.98
263.0
263.1
263.9
280.0–280.9
285.9
287.30-287.39
288.00-288.09
288.4
288.50-288.59
288.60-288.69
288.8
289.53
294.8
310.1
322.2
331.19
331.83
336.9
348.30
348.39
354.0–354.9
PeaceHealth Laboratories | Medicare Coverage Policies
49
86689, 86701, 86702, 86703, 87390, 87391,
87534, 87535, 87537, 87538
Other specified idiopathic peripheral neuropathy
Chorioretinitis, unspecified
Other primary cardiomyopathies
Chronic sinusitis
Pneumococcal pneumonia
Pneumonia in cytomegalic inclusion disease
Pneumonia, organism unspecified
Primary spontaneous pneumothorax
Secondary spontaneous pneumothorax
Chronic pneumothorax
Other specified alveolar and parietoalveolar pneumonopathies
Oral aphthae
Leukoplakia of oral mucosa
Ulcer of esophagus without bleeding
Ulcer of esophagus with bleeding
Barrett’s esophagus
Nephropathy with unspecified pathological lesion in kidney
Secondary hyperparathyroidism (of renal origin)
Other specified disorders resulting from impaired renal function
Other viral diseases complicating pregnancy (use for HIV I and II)
Other cellulitis and abscess
Seborrheic dermatitis
Other psoriasis
Lichenification and lichen simplex chronicus
Other specified diseases of hair and hair follicles
Diseases of sebaceous glands
Fever, unspecified
Fever presenting with conditions classified elsewhere
Postprocedural fever
Postvaccination fever
Chills (without fever)
Hypothermia not associated with low environmental temperature
Febrile nonhemolytic transfusion reaction
Other malaise and fatigue
Abnormal loss of weight
Lack of expected normal physiological development
Enlargement of lymph nodes
Respiratory abnormality, unspecified
Shortness of breath
Cough
Hemoptysis
Abnormal sputum
Diarrhea
Nonspecific serologic evidence of human immunodefiency virus
Wasting disease
Contact or exposure to varicella
HIV Testing: diagnosis….con’t
356.8
363.20
425.4
473.0–473.9
481–482.9
484.1
486
512.81
512.82
512.83
516.8
528.2
528.6
530.20
530.21
530.85
583.9
588.81
588.89
647.60–647.64
682.0–682.9
690.10–690.18
696.1
698.3
704.8
706.0–706.9
780.60
780.61
780.62
780.63
780.64
780.65
780.66
780.79
783.21
783.40
785.6
786.00
786.05
786.2
786.30-786.39
786.4
787.91
795.71
799.4
V01.71
PeaceHealth Laboratories | Medicare Coverage Policies
50
86689, 86701, 86702, 86703, 87390, 87391,
87534, 87535, 87537, 87538
Contact or exposure to other viral diseases
Rape
HIV Testing: diagnosis….con’t
V01.79
V71.5
PeaceHealth Laboratories | Medicare Coverage Policies
51
HIV testing: prognosis, including monitoring
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
87536
87539
ICD-9 CODES
042
079.53
647.60–647.64
795.71
V08
TEST NAME
Infectious agent detection by nucleic acid (DNA or RNA); HIV–1,
quantification
Infectious agent detection by nucleic acid (DNA or RNA); HIV–2,
quantification
ICD-9 DESCRIPTIONS
Human immunodeficiency virus [HIV] disease
Human immunodeficiency virus, type 2 [HIV–2]
Other viral diseases complicating pregnancy (including HIV–I and II)
Nonspecific serologic evidence of human immunodeficiency virus [HIV]
Asymptomatic human immunodeficiency virus [HIV] infection status
PeaceHealth Laboratories | Medicare Coverage Policies
52
Iron Studies
Policy Type: NCD (National Coverage
Decision)
CPT CODE(S)
82728
83540
83550
84466
ICD-9 CODES
002.0–002.9
003.0–003.9
006.0–006.9
007.0–007.9
008.00–008.8
009.0–009.3
011.50–011.56
014.00–014.86
015.00–015.96
016.00–016.06
016.10–016.16
016.20–016.26
016.30–016.36
042
070.0–070.9
140.0–149.9
150.0–159.9
160.0–165.9
170.0–176.9
179–189.9
190.0–199.2
200.00–208.92
209.00-209.03
209.10-209.17
209.20-209.27,
209.29
209.30-209.36
209.40-209.43
209.50-209.57
209.60-209.67,
209.69
209.70-209.79
210.0–229.9
230.0–234.9
235.0–238.9
239.0–239.9
TEST NAME
Ferritin
Iron
Iron Binding capacity
Transferrin
ICD-9 DESCRIPTIONS
Typhoid and paratyphoid fevers
Other salmonella infections
Amebiasis
Other protozoal intestinal diseases
Intestinal infections due to other organisms
Ill-defined intestinal infections
Tuberculous bronchiectasis
Tuberculosis of intestines, peritoneum, and mesenteric glands
Tuberculosis of bones and joints
Tuberculosis of kidney
Tuberculosis of bladder
Tuberculosis of ureter
Tuberculosis of other urinary organs
Human Immunodeficiency virus (HIV) disease
Viral hepatitis
Malignant neoplasm of lip oral cavity and pharynx
Malignant neoplasm of digestive organs and peritoneum
Malignant neoplasm of respiratory and intrathoracic organs
Malignant neoplasm of bone, connective tissue, skin and breast
Malignant neoplasm of genitourinary organs
Malignant neoplasm of other and unspecified sites
Malignant neoplasm of lymphatic and hematopoietic tissue
Malignant carcinoid tumors of the small intestine
Malignant carcinoid tumors of the appendix, large intestine, and rectum
Malignant carcinoid tumors of other and unspecified sites
Merkel cell carcinoma
Benign carcinoid tumors of the small intestine
Benign carcinoid tumors of the appendix, large intestine, and rectum
Benign carcinoid tumor of other and unspecified sites
Secondary neuroendocrine tumor
Benign neoplasms
Carcinoma in situ
Neoplasms of uncertain behavior
Neoplasms of unspecified nature
PeaceHealth Laboratories | Medicare Coverage Policies
53
Iron Studies……con’t
249.00-249.91
250.00–250.93
253.2
253.7
253.8
256.31-256.39
257.2
260
261
262
263.0–263.9
275.01-275.09
277.1
280.0–280.9
281.0–281.9
282.40-282.49
282.60-282.69
285.0
285.1
285.21
285.22
285.29
285.3
285.9
286.0–286.9
287.0–287.9
289.52
306.4
307.1
307.50–307.59
403.01
403.11
403.91
404.02
404.03
404.12
404.13
404.92
82728, 83540, 83550, 84466
Secondary diabetes mellitus
Diabetes mellitus
Panhypopituitarism
Iatrogenic pituitary disorders
Other disorders of the pituitary and other syndromes of
diencephalohypophyseal origin
Other ovarian failure
Other testicular hypofunction
Kwashiorkor
Nutritional marasmus
Other severe protein-calorie malnutrition
Other and unspecified protein-calorie malnutrition
Disorders of iron metabolism
Disorders of porphyrin metabolism
Iron deficiency anemias
Other deficiency anemias
Thalassemias
Sickle-cell anemia
Sideroblastic anemia (includes hemochromatosis with refractory anemia)
Acute post-hemorrhagic anemia
Anemia in chronic kidney disease
Anemia in neoplastic disease
Anemia of other chronic disease
Antineoplastic chemotherapy induced anemia
Anemia, unspecified
Coagulation defects (congenital factor disorders)
Purpura and other hemorrhagic conditions
Splenic sequestration
Physiological malfunction arising from mental factors, gastrointestinal
Anexoria nervosa
Other and unspecified disorders of eating
Hypertensive kidney disease, malignant, with chronic kidney disease
Hypertensive kidney disease, benign, with chronic kidney disease
Hypertensive kidney disease, unspecified, with chronic kidney disease
Hypertensive heart and kidney disease, malignant, with chronic kidney
disease
Hypertensive heart and kidney disease, malignant, with heart failure
and chronic kidney disease
Hypertensive heart and kidney disease, benign, with chronic kidney
disease
Hypertensive heart and kidney disease, benign, with heart failure and
chronic kidney disease
Hypertensive heart and kidney disease, unspecified, with chronic
kidney disease
PeaceHealth Laboratories | Medicare Coverage Policies
54
Iron Studies……con’t
404.93
425.4
425.5
425.7
425.8
425.9
426.0–426.9
427.0–427.9
428.0–428.9
530.7
530.82
531.00–531.91
532.00–532.91
533.00–533.91
534.00–534.91
535.00–535.71
536.0–536.9
537.83
537.84
555.0–555.9
556.0–556.9
557.0
557.1
562.02
562.03
562.12
562.13
569.3
569.85
569.86
569.87
570
571.0–571.9
572.0–572.8
573.0–573.9
578.0–578.9
579.0–579.3
579.8–579.9
581.0–581.9
585.4
585.5
585.6
585.9
586
608.3
82728, 83540, 83550, 84466
Hypertensive heart and kidney disease, unspecified, with heart failure
and chronic kidney disease
Other primary cardiomyopathies
Alcoholic cardiomyopathy
Nutritional and metabolic cardiomyopathy
Cardiomyopathy in other diseases classified elsewhere
Secondary cardiomyopathy, unspecified
Conduction disorders
Cardiac dysrhythmias
Heart Failure
Gastroesophageal laceration-hemorrhage syndrome
Esophageal hemorrhage
Gastric ulcer
Duodenal ulcer
Peptic ulcer, site unspecified
Gastrojejunal ulcer
Gastritis and duodenitis
Disorders of function of stomach
Angiodysplasia of stomach and duodenum with hemorrhage
Dieulafoy lesion (hemorrhagic) of stomach and duodenum
Regional enteritis
Ulcerative colitis
Acute vascular insufficiency of intestine
Chronic vascular insufficiency of intestine
Diverticulosis of small intestine with hemorrhage
Diverticulitis of small intestine with hemorrhage
Diverticulosis of colon with hemorrhage
Diverticulitis of colon with hemorrhage
Hemorrhage of rectum and anus
Angiodysplasia of intestine with hemorrhage
Dieulafoy lesion (hemorrhagic) of intestine
Vomiting of fecal matter
Acute and subacute necrosis of liver
Chronic liver disease and cirrhosis
Liver abscess and sequelae of chronic liver disease
Other disorders of liver
Gastrointestinal hemorrhage
Intestinal malabsorption
Other specified and unspecified intestinal malabsorption
Nephrotic syndrome
Chronic kidney disease, Stage IV (severe)
Chronic kidney disease, Stage V
End stage renal disease
Chronic kidney disease, unspecified
Renal failure, unspecified
Atrophy of testis
PeaceHealth Laboratories | Medicare Coverage Policies
55
Iron Studies……con’t
626.0–626.9
627.0
627.1
648.20–648.24
698.0–698.9
704.00–704.09
709.00–709.09
713.0
716.40–716.99
719.40–719.49
773.2
773.3
773.4
773.5
783.9
790.01-790.09
790.4
790.5
790.6
799.4
964.0
984.0–984.9
996.85
999.80
999.83
999.84
999.85
999.89
V08
V12.1
V12.3
V15.1
V15.21
V15.22
V15.29
V43.21
V43.22
V43.3
V43.4
V43.60
V56.0
V56.8
82728, 83540, 83550, 84466
Disorders of menstruation and other abnormal bleeding from female genital
tract
Premenopausal menorrhagia
Postmenopausal bleeding
Other current conditions in the mother classifiable elsewhere, but complicating
pregnancy, childbirth, or the puerperium: Anemia
Pruritis and related conditions
Alopecia
Dyschromia
Arthropathy associated with other endocrine and matabolic disorders
Other and unspecified arthropathies
Pain in joint
Hemolytic disease due to other and unspecified isoimmunization
Hydrops fetalis due to isoimmunization
Kernicterus due to isoimmunization
Late anemia due to isoimmunization
Other symptoms concerning nutrition, metabolism and development
Abnormality of red blood cells
Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase
[LDH]
Other nonspecific abnormal serum enzyme levels
Other abnormal blood chemistry
Cachexia
Poisoning by agents primarily affecting blood constituents, iron compounds
Toxic effect of lead and its compounds (including fumes)
Complications of transplanted organ, bone marrow
Transfusion reaction, unspecified
Hemolytic transfusion reaction, incompatibility unspecified
Acute hemolytic transfusion reaction, incompatibility unspecified
Delayed hemolytic transfusion reaction, incompatibility unspecified
Other transfusion reactions
Asymptomatic HIV infection
Personal history of nutritional deficiency
Personal history of diseases of blood and blood forming organs
Personal history of surgery to heart and great vessels
Personal history of undergoing in utero procedure during pregnancy
Personal history of undergoing in utero procedure while a fetus
Surgery to other organs
Heart assist device
Fully implantable artificial heart
Heart valve replaced by other means
Blood vessel replaced by other means
Unspecified joint replaced by other means
Extracorporeal dialysis
Other dialysis
PeaceHealth Laboratories | Medicare Coverage Policies
56
Lipids Testing
Policy Type: NCD (National Coverage
Decision)
The lipid NCD is being subdivided into two parts in order to implement the new
cardiovascular and diabetes screening benefits that were added to Medicare by
the MMA.
CPT CODE(S)
80061
82465
83718
84478
ICD-9 CODES
242.00–245.9
249.00-249.01
249.10-249.11
249.20-249.21
249.30-249.31
249.40-249.41
249.50-249.51
249.60-249.61
249.70-249.71
249.80-249.81
249.90-249.91
250.00–250.93
255.0
260
261
262
263.0
263.1
263.8
263.9
270.0
271.1
272.0
272.1
272.2
272.3
272.4
272.5
272.6
272.7
272.8
TEST NAME
Lipid panel
Cholesterol, serum or whole blood, total
Lipoprotein, direct measurement; high density cholesterol (HDL
cholesterol)
Triglycerides
ICD-9 DESCRIPTIONS
Disorders of the thyroid gland with hormonal dysfunction
Secondary diabetes mellitus without mention of complication
Secondary diabetes mellitus with ketoacidosis
Secondary diabetes mellitus with hyperosmolarity
Secondary diabetes mellitus with other coma
Secondary diabetes mellitus with renal manifestations
Secondary diabetes mellitus with ophthalmic manifestations
Secondary diabetes mellitus with neurological manifestations
Secondary diabetes mellitus with peripheral circulatory disorders
Secondary diabetes mellitus with other specified manifestations
Secondary diabetes mellitus with unspecified complication
Diabetes mellitus
Cushing’s syndrome
Kwashiorkor
Nutritional marasmus
Other severe, protein-calorie malnutrition
Malnutrition of moderate degree
Malnutrition of mild degree
Other protein-calorie malnutrition
Unspecified protein-calorie malnutrition
Disturbances of amino-acid transport
Galactosemia
Pure hypercholesterolemia
Hyperglyceridemia
Mixed hyperlipidemia (tuberous xanthoma)
Hyperchylomicronemia
Other and unspecified hyperlipidemia (unspecified xanthoma)
Lipoprotein deficiencies
Lipodystrophy
Lipidoses
Other disorders of lipoid metabolism
PeaceHealth Laboratories | Medicare Coverage Policies
57
Lipids Testing……con’t
80061, 82465, 83718, 84478
272.9
Unspecified disorders of lipoid metabolism
277.30-277.39
Amyloidosis
278.00
Obesity
278.01
Morbid obesity
278.02
Overweight
278.03
Obesity hypoventilation syndrome
303.90–303.92
Alcoholism
362.10–362.16
Other background retinopathy and retinal vascular change
362.30–362.34
Retinal vascular occlusion
362.82
Retinal exudates and deposits
371.41
Corneal arcus, juvenile
374.51
Xanthelasma
379.22
Crystalline deposits in vitreous
388.00
Degenerative & vascular disorder of ear, unspecified
388.02
Transient ischemic deafness
401.0, 401.1, 401.9
Essential hypertension
402.00–402.91
Hypertensive heart disease
403.00–403.91
Hypertensive kidney disease
404.00–404.93
Hypertensive heart and kidney disease
405.01–405.99
Secondary hypertension
410.00–410.92
Acute myocardial infarction
411.0–411.1
Other acute & subacute forms of ischemic heart disease
411.81
Coronary occlusion without myocardial infarction
411.89
Other acute and subacute ischemic heart disease
412
Old myocardial infarction
413.0–413.1
Angina pectoris
413.9
Other and unspecified angina pectoris
414.00–414.03
Coronary atherosclerosis
414.04
Coronary athrscl-artery bypass graft
414.05
Coronary athrscl-unspec graft
414.06
Coronary athrscl-of coronary artery of transplanted heart
414.07
Coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
414.10
Aneurysm of heart (wall)
414.11
Coronary vessel aneurysm
414.12
Dissection of coronary artery
414.19
Other aneurysm of heart
414.3
Coronary atherosclerosis due to lipid rich plaque
414.4
Coronary atherosclerosis due to calcified coronary lesion
414.8
Other specified forms of chronic ischemic heart disease
414.9
Chronic ischemic heart disease, unspecified
428.0–428.9
Heart failure
429.2
Arteriosclerotic cardiovascular disease
429.9
Heart disease NOS
431
Intracerebral hemorrhage
433.00–433.91
Occlusion & stenosis of precerebral arteries
434.00–434.91
Occlusion of cerebral arteries
435.0–435.9
Transient cerebral ischemia
PeaceHealth Laboratories | Medicare Coverage Policies
58
Lipids Testing……con’t
80061, 82465, 83718, 84478
437.0
Other & ill-defined cerebrovascular disease
437.1
Other generalized ischemic cerebrovascular disease
437.5
Moyamoya disease
438.0, 438.10438.14, 438.19,
438.20-438.22,
438.30-438.32,
Late effects of cerebrovascular disease
438.40-438.42,
438.50-438.53,
438.6, 438.7, 438.81438.85, 438.89, 438.9
440.0-440.32
Arteriosclerosis of aorta; of other arteries; of bypass grafts
440.4
Chronic total occlusion of the artery of the extremities
Atherosclerosis of other specified arteries; generalized and unspecified
440.8-440.9
atherosclerosis
441.00–441.9
Aortic aneurysms
442.0
Upper extremity aneurysm
442.1
Renal artery aneurysm
442.2
Iliac artery aneurysm
444.01, 444.09,
Arterial embolism & thrombosis
444.1-444.9
557.1
Chronic vascular insufficiency of intestine
571.8
Other chronic non-alcoholic liver disease
571.9
Unspecified chronic liver disease without mention of alcohol
573.5
Hepatopulmonary syndrome
573.8
Other specified disorders of liver
573.9
Unspecified disorders of liver
577.0–577.9
Pancreatic disease
579.3
Other & unspecified postsurgical nonabsorption
579.8
Other specified intestinal malabsorption
581.0–581.9
Nephrotic syndrome
584.5
Acute renal failure with lesion of tubular necrosis
585.4
Chronic kidney disease, Stage IV (severe)
585.5
Chronic kidney disease, Stage V
585.6
End stage renal disease
585.9
Chronic kidney disease, unspecified
588.0
Renal osteodystrophy
588.1
Nephrogenic diabetes insipidus
588.81
Secondary hyperparathyroidism (of renal origin)
588.89
Other specified disorders resulting from impaired renal function
588.9
Unspecified disorder resulting from impaired renal function
607.84
Impotence of organic origin, penis disorder
646.70–646.71
Liver disorders in pregnancy
646.73
Liver disorder antepartum
648.10–648.14
Thyroid disfunction in pregnancy and the puerperium
696.0
Psoriatic arthropathy
696.1
Other psoriasis
PeaceHealth Laboratories | Medicare Coverage Policies
59
Lipids Testing……con’t
80061, 82465, 83718, 84478
751.61
Biliary atresia
764.10–764.19
‘‘Light for dates’’ with signs of fetal malnutrition
786.50
Chest pain, unspecified
786.51
Precordial pain
786.59
Chest pain, other
789.1
Hepatomegaly
790.4
Abnormal transaminase
790.5
Abnormal alkaline phosphatase
790.6
Other abnormal blood chemistry
Nonspecific (abnormal) findings on radiological and other examination of
793.4
gastrointestinal tract
987.9
Toxic effect of unspecified gas or vapor
996.81
Complication of transplanted organ, kidney
V42.0
Transplanted organ, kidney
V42.7
Organ replacement by transplant, liver
V58.63-V58.64
Long-term (current) drug use
V58.69
Long term (current) use of other medications
The following are screening codes that Medicare will cover only once every 5
years. Please advise your patient that Medicare may deem this test patient
responsibility based on this frequency limitation.
V81.0
V81.1
V81.2
Screening for ischemic heart disease
Screening for hypertension
Screening for other unspecified cardiovascular conditions
PeaceHealth Laboratories | Medicare Coverage Policies
60
Lipids Testing
Policy Type: NCD (National Coverage Decision)
The lipid NCD is being subdivided into two parts in order to implement the new
cardiovascular and diabetes screening benefits that were added to Medicare by
the MMA.
CPT CODE(S)
83700
83701
TEST NAME
Lipoprotein, blood; electrophoretic separation and quantitation
Lipoprotein, blood; high resolution fractionation and quantitation of
lipoproteins including lipoprotein subclasses when performed
83704
Lipoprotein, blood; quantitation of lipoprotein particle numbers and
lipoprotein particle subclasses (e.g., by nuclear magnetic resonance
spectroscopy)
83721
Lipoprotein, direct measurement, LDL cholesterol
ICD-9 CODES
242.00–245.9
249.00-249.01
249.10-249.11
249.20-249.21
249.30-249.31
249.40-249.41
249.50-249.51
249.60-249.61
249.70-249.71
249.80-249.81
249.90-249.91
250.00–250.93
255.0
260
261
262
263.0
263.1
263.8
263.9
270.0
271.1
272.0
272.1
272.2
272.3
272.4
272.5
272.6
272.7
ICD-9 DESCRIPTIONS
Disorders of the thyroid gland with hormonal dysfunction
Secondary diabetes mellitus without mention of complication
Secondary diabetes mellitus with ketoacidosis
Secondary diabetes mellitus with hyperosmolarity
Secondary diabetes mellitus with other coma
Secondary diabetes mellitus with renal manifestations
Secondary diabetes mellitus with ophthalmic manifestations
Secondary diabetes mellitus with neurological manifestations
Secondary diabetes mellitus with peripheral circulatory disorders
Secondary diabetes mellitus with other specified manifestations
Secondary diabetes mellitus with unspecified complication
Diabetes mellitus
Cushing’s syndrome
Kwashiorkor
Nutritional marasmus
Other severe, protein-calorie malnutrition
Malnutrition of moderate degree
Malnutrition of mild degree
Other protein-calorie malnutrition
Unspecified protein-calorie malnutrition
Disturbances of amino-acid transport
Galactosemia
Pure hypercholesterolemia
Hyperglyceridemia
Mixed hyperlipidemia (tuberous xanthoma)
Hyperchylomicronemia
Other and unspecified hyperlipidemia (unspecified xanthoma)
Lipoprotein deficiencies
Lipodystrophy
Lipidoses
PeaceHealth Laboratories | Medicare Coverage Policies
61
Lipids Testing……con’t
272.8
272.9
277.30-277.39
278.00
278.01
278.02
278.03
303.90–303.92
362.10–362.16
362.30–362.34
362.82
371.41
374.51
379.22
388.00
388.02
401.0, 401.1, 401.9
402.00–402.91
403.00–403.91
404.00–404.93
405.01–405.99
410.00–410.92
411.0–411.1
411.81
411.89
412
413.0–413.1
413.9
414.00–414.03
414.04
414.05
414.06
414.07
414.10
414.11
414.12
414.19
414.3
414.4
414.8
414.9
428.0–428.9
429.2
429.9
431
433.00–433.91
83700, 83701, 83704,83721
Other disorders of lipoid metabolism
Unspecified disorders of lipoid metabolism
Amyloidosis
Obesity
Morbid obesity
Overweight
Obesity hypoventilation syndrome
Alcoholism
Other background retinopathy and retinal vascular change
Retinal vascular occlusion
Retinal exudates and deposits
Corneal arcus, juvenile
Xanthelasma
Crystalline deposits in vitreous
Degenerative & vascular disorder of ear, unspecified
Transient ischemic deafness
Essential hypertension
Hypertensive heart disease
Hypertensive renal disease
Hypertensive heart and renal disease
Secondary hypertension
Acute myocardial infarction
Other acute & subacute forms of ischemic heart disease
Coronary occlusion without myocardial infarction
Other acute and subacute ischemic heart disease
Old myocardial infarction
Angina pectoris
Other and unspecified angina pectoris
Coronary atherosclerosis
Coronary athrscl-artery bypass graft
Coronary athrscl-unspec graft
Coronary athrscl-of coronary artery of transplanted heart
Coronary atherosclerosis of bypass graft (artery) (vein) of transplanted heart
Aneurysm of heart (wall)
Coronary vessel aneurysm
Dissection of coronary artery
Other aneurysm of heart
Coronary atherosclerosis due to lipid rich plaque
Coronary atherosclerosis due to calcified coronary lesion
Other specified forms of chronic ischemic heart disease
Chronic ischemic heart disease, unspecified
Heart failure
Arteriosclerotic cardiovascular disease
Heart disease NOS
Intracerebral hemorrhage
Occlusion & stenosis of precerebral arteries
PeaceHealth Laboratories | Medicare Coverage Policies
62
Lipids Testing……con’t
434.00–434.91
435.0–435.9
437.0
437.1
437.5
438.0, 438.10-438.14,
438.19, 438.20-438.22,
438.30-438.32, 438.40438.42,438.50-438.53,
438.6, 438.7, 438.81438.85, 438.89, 438.9
440.0–440.32
440.4
440.8-440.9
441.00–441.9
442.0
442.1
442.2
444.01, 444.09, 444.1444.9
557.1
571.8
571.9
573.5
573.8
573.9
577.0–577.9
579.3
579.8
581.0–581.9
584.5
585.4
585.5
585.6
585.9
588.0
588.1
588.81
588.89
588.9
607.84
646.70–646.71
646.73
648.10–648.14
83700, 83701, 83704, 83721
Occlusion of cerebral arteries
Transient cerebral ischemia
Other & ill-defined cerebrovascular disease
Other generalized ischemic cerebrovascular disease
Moyamoya disease
Late effects of cerebrovascular disease
Atherosclerosis of aorta; of other arteries; of bypass grafts
Chronic total occlusion of the artery of the extremities
Atherosclerosis of other specified arteries; generalized and unspecified
atherosclerosis
Aortic aneurysms
Upper extremity aneurysm
Renal artery aneurysm
Iliac artery aneurysm
Arterial embolism & thrombosis
Chronic vascular insufficiency of intestine
Other chronic non-alcoholic liver disease
Unspecified chronic liver disease without mention of alcohol
Hepatopulmonary syndrome
Other specified disorders of liver
Unspecified disorders of liver
Pancreatic disease
Other & unspecified postsurgical nonabsorption
Other specified intestinal malabsorption
Nephrotic syndrome
Acute renal failure with lesion of tubular necrosis
Chronic kidney disease, Stage IV (severe)
Chronic kidney disease, Stage V
End stage renal disease
Chronic kidney disease, unspecified
Renal osteodystrophy
Nephrogenic diabetes insipidus
Secondary hyperparathyroidism (of renal origin)
Other specified disorders resulting from impaired renal function
Unspecified disorder resulting from impaired renal function
Impotence of organic origin, penis disorder
Liver disorders in pregnancy
Liver and biliary tract disorders in pregnancy, antepartum condition or
complication
Thyroid dysfunction in pregnancy and the puerperium
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63
Lipids Testing……con’t
696.0
696.1
751.61
764.10–764.19
786.50
786.51
786.59
789.1
790.4
790.5
790.6
793.4
987.9
996.81
V42.0
V42.7
V58.63
V58.64
V58.69
83700, 83701, 83704, 83721
Psoriatic arthropathy
Other psoriasis
Biliary atresia
‘‘Light for dates’’ with signs of fetal malnutrition
Chest pain, unspecified
Precordial pain
Chest pain, other
Hepatomegaly
Abnormal transaminase
Abnormal alkaline phosphatase
Other abnormal blood chemistry
Abnormal imaging study
Toxic effect of unspecified gas or vapor
Complication of transplanted organ, kidney
Transplanted organ, kidney
Organ replacement by transplant, liver
Long-term (current) use of antiplatelets/antithrombotics
Long-term (current) use of non-steroidal anti-inflammatories (NSAID)
Long term (current) use of other medications
PeaceHealth Laboratories | Medicare Coverage Policies
64
Occult Blood,
Diagnostic
CPT CODE(S)
82272
ICD-9 CODES
003.0
003.1
004.0–004.9
005.0–005.9
006.0–006.9
007.0–007.9
008.41–008.49
009.0–009.3
014.00–014.86
040.2
095.2
095.3
098.0
098.7
098.84
123.0–123.9
124
127.0–127.9
139.8
150.0–157.9
159.0—159.9
176.3
197.4–197.5
197.8
199.0
204.00–204.92
205.00–208.92
209.00–209.03
209.10–209.17
209.40–209.43
209.50–209.57
209.70–209.74
209.75
209.79
211.0–211.9
Policy Type: NCD (National Coverage Decision)
TEST NAME
Blood, occult, by peroxidase activity (e.g. guaiac), qualitative, feces, 1-3
simultaneous determinations, performed for other than colorectal
neoplasm screening
ICD-9 DESCRIPTIONS
Salmonella gastroenteritis
Salmonella septicemia
Shigellosis
Other food poisoning (bacterial)
Amebiasis
Other protozoal intestinal diseases
Intestinal infections due to other specified bacteria
Ill-defined intestinal infections
Tuberculosis of intestines, peritoneum, and mesenteric glands
Whipple’s disease
Syphilitic peritonitis
Syphilis of liver
Gonococcal infections, acute, lower enitourinary tract
Gonococcal infection anus and rectum
Gonococcal endocaritis
Other cestode infection
Trichinosis
Other intestinal helminthiases
Late effects of other and unspecified infectious and parasitic diseases
Malignant neoplasm of digestive organisms
Malignant neoplasm of other and ill-defined sites within the digestive organs
and peritoneum
Kaposi’s sarcoma, gastrointestinal sites
Secondary malignant neoplasm of intestines
Secondary malignant neoplasm of other digestive organs and spleen
Disseminated malignant neoplasm
Lymphoid leukemia
Leukemia
Malignant carcinoid tumors of the small intestine
Malignant carcinoid tumors of the appendix, large intestine, and rectum
Benign carcinoid tumors of the small intestine
Benign carcinoid tumors of the appendix, large intestine, and rectum
Secondary neuroendocrine tumor
Secondary Merkel cell carcinoma
Secondary neuroendocrine tumor of other sites
Benign neoplasm of other parts of digestive system
PeaceHealth Laboratories | Medicare Coverage Policies
65
Occult Blood……con’t
228.04
230.2–230.9
235.2
235.5
239.0
280.0–280.9
284.2
285.0–285.9
286.0–286.9
287.0–287.9
338.3
448.0
455.0–455.8
456.0–456.21
530.10-530.21, 530.3530.7, 530.81-530.89,
530.9
531.00-535.61
535.70–535.71
536.2
536.8–536.9
537.0–537.4
537.82–537.83
537.84
537.89
555.0–558.3
558.41
558.42
558.9
560.0–560.39
562.10–562.13
564.00–564.9
565.0–565.1
569.0
569.1
569.3
569.41–569.44, 569.49
569.82–569.83
569.84–569.85
569.86
569.87
571.0–571.9
577.0–577.9
578.0–578.9
579.0
82272
Hemangioma of intra-abdominal structures
Carcinoma in situ of digestive organs
Neoplasm of uncertain behavior of stomach, intestines, and rectum
Neoplasm of uncertain behavior of other and unspecified digestive organs
Neoplasm of unspecified nature, digestive system
Iron deficiency anemias
Myelophthisis
Other and unspecified anemias
Coagulation defects
Purpura and other hemorrhagic conditions
Neoplasm related pain (acute) (chronic)
Hereditary hemorrhagic telangiectasia
Hemorrhoids
Esophageal varices with or without mention of bleeding
Diseases of the esophagus
Gastric ulcer; duodenal ulcer; peptic ulcer, site unspecified; gastrojejunal ulcer;
and gastritis and duodenitis
Eosinophilic gastritis
Persistent vomiting
Dyspepsia and other specified and unspecified functional disorders of the
stomach
Other disorders of stomach and duodenum
Angiodysplasia of stomach and duodenum
Dieulafoy lesion (hemorrhagic) of stomach and duodenum
Other specified disorders of stomach and duodenum
Non-infectious enteritis and colitis
Eosinophilic gastroenteritis
Eosinophilic colitis
Non-infectious enteritis and colitis
Intestinal obstruction/impaction without mention of hernia
Diverticulosis/diverticulitis of colon
Functional digestive disorders, not elsewhere classified
Anal fissure and fistula
Anal and rectal polyp
Rectal prolapse
Hemorrhage of rectum and anus
Other specified disorders of rectum and anus
Ulceration and perforation of intestine
Angiodysplasia of intestine with or without mention of hemorrhage
Dieulafoy lesion (hemorrhagic) of intestine
Vomiting of fecal matter
Chronic liver disease and cirrhosis
Diseases of the pancreas
Gastrointestinal hemorrhage
Celiac disease
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66
Occult Blood……con’t
579.8
596.1
617.5
780.71
780.72
780.79
783.0
783.21
787.01–787.03
787.04
787.1
787.20-787.29
787.7
787.91
787.99
789.00–789.09
789.30–789.39
789.40–789.49
789.51
789.59
789.60–789.69
789.7
790.92
792.1
793.6
794.8
863.0–863.90
863.91-863.95, 863.99
864.00–864.09
864.11–864.19
866.00–866.03
866.10–866.13
902.0–902.9
926.11–926.19
926.8
926.9
964.2
995.20
995.24
V10.00–V10.09
V12.00
V12.72
V58.61
V58.63-V58.65
V58.66
V58.69
82272
Other specified intestinal malabsorption
Intestinovesical fistula
Endometriosis of intestine
Chronic fatigue syndrome
Functional quadriplegia
Other malaise and fatigue
Anorexia
Abnormal loss of weight
Nausea and vomiting
Bilious emesis
Heartburn
Dysphagia
Abnormal feces
Diarrhea
Other symptoms involving digestive system
Abdominal pain
Abdominal or pelvic swelling, mass, or lump
Abdominal rigidity
Malignant ascites
Other ascites
Abdominal tenderness
Colic
Abnormal coagulation profile
Nonspecific abnormal findings in stool contents
Nonspecific abnormal findings on radiological and other examination,
abdominal area, including retroperitoneum
Nonspecific abnormal results of function studies, liver
Injury to gastrointestinal tract
Injury to gastrointestinal tract
Injury to liver without mention of open wound into cavity
Injury to liver with open wound into cavity
Injury to kidney without mention of open wound into cavity
Injury to kidney with open wound into cavity
Injury to blood vessels of abdomen and pelvis
Crushing injury of trunk, other specified sites
Crushing injury of trunk, multiple sites
Crushing injury of trunk, unspecified site
Poisoning by agents primarily affecting blood constituents, anticoagulants
Unspecified adverse effect of drug, medicinal, and biological substance
Failed moderate sedation during procedure
Personal history of malignant neoplasm, gastrointestinal tract
Personal history of unspecified infectious and parasitic disease
Personal history of colonic polyps
Long term (current) use of anticoagulants
Long term (current) drug use
Long term (current) use of aspirin
Long term (current) use of other medications
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67
Occult Blood……con’t
V67.51
82272
Following treatment with high risk medication, not elsewhere specified
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68
Partial Thromboplastin Time (PTT)
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
85730
ICD-9 CODES
002.0–002.9
003.0–003.9
038.9
042
060.0–060.9
065.0–065.9
070.0–070.9
075
078.6
078.7
120.0
121.1
121.3
124
135
155.0–155.2
197.7
238.4
238.71-238.79
239.9
246.3
249.40
249.41
250.40–250.43
269.0
273.0–273.9
275.01–275.9
277.1
277.30-277.39
285.1
286.0
286.1
286.2–286.3
286.4
286.52
286.53
286.59
286.6
TEST NAME
Thromboplastin time, partial (PTT); plasma or whole blood
ICD-9 DESCRIPTIONS
Typhoid and paratyphoid
Other Salmonella infections
Unspecified Septicemia
Human immunodeficiency virus (HIV) disease
Yellow fever
Arthopod borne hemorrhagic fever
Viral Hepatitis
Infectious mononucleosis
Hemorrhagic nephrosonephritis
Arenaviral hemorrhagic fever
Schistosomiasis haematobium
Clonorchiasis
Fascioliasis
Trichinosis
Sarcoidosis
Malignant neoplasm of liver and intrahepatic bile ducts
Malignant neoplasm of liver, specified as secondary
Polycythemia vera
Lymphatic and hemapoietic tissues
Neoplasm of unspecified nature, site unspecified
Hemorrhage and infarction of thyroid
Secondary diabetes mellitus with renal manifestations, not uncontrolled
Secondary diabetes mellitus with renal manifestations, uncontrolled
Diabetic with renal manifestations
Deficiency of Vitamin K
Disorders of plasma protein metabolism
Disorders of iron metabolism
Disorders of porphyrin metabolism
Amyloidosis
Acute posthemorrhagic anemia
Congenital factor VIII disorder—Hemophilia A
Congenital factor IX disorder—Hemophilia B
Other congenital factor deficiencies
von Willebrand’s disease
Acquired hemophilia
Antiphospholipid antibody with hemorrhagic disorder
Other hemorrhagic disorder due to intrinsic circulating anticoagulants,
antibodies, or inhibitors
Defibrination syndrome
PeaceHealth Laboratories | Medicare Coverage Policies
69
PTT……..con’t
286.7
286.9
287.0–287.9
289.0
289.81
325
360.43
362.30–362.37
362.43
362.81
363.61-363.63
363.72
368.9
372.72
374.81
376.32
377.42
379.23
380.31
403.01, 403.11,
403.91
404.02, 404.12,
404.92
410.00–410.92
423.0
427.31
427.9
428.0
429.79
430–432.9
433.00–433.91
434.00–434.91
435.9
444.01–444.9
446.6
447.2
448.0
451.0–451.9
453.0–453.9
456.0
456.1
456.8
459.89
530.7
530.82
531.00–535.71
537.83
85730
Acquired coagulation factor deficiency
Other and unspecified coagulation defects
Purpura and other hemorrhagic conditions
Polycythemia, secondary
Primary hypercoagulable state
Phlebitis and thrombophlebitis of intracranial ventricles sinuses
Hemophthalmos, except current injury
Retinal vasclar occlusion
Hemorrhagic detachmentof retinal pigment epithelium
Retinal hemorrhage
Choroidal hemorrhage
Choroidal detachment
Unspecified Visual Disturbances
Conjunctive hemorrhage
Hemorrhage of eyelid
Orbital hemorrhage
Hemorrhage in optic nerve sheaths
Vitreous hemorrhage
Hematoma of auricle or pinna
Hypertensive kidney disease with chronic kidney disease
Hypertensive heart and kidney disease with chronic kidney disease
Acute myocardial infarction
Hemopericardium
Atrial fibrillation
Cardiac dysrhythmias, unspecified
Congestive heart failure, unspecified
Mural thrombus
Cerebral hemorrhage
Occlusion and stenosis of precerebral arteries
Occlusion of cerebral arteries
Focal neurologic deficit
Arterial embolism and thrombosis
Thrombotic microangiopathy
Rupture of artery
Hereditary Hemorrhagic telangiectasia
Phlebitis and thrombophlebitis
Other Venous emboli and thrombosis
Esophageal varices with bleeding
Esophageal varices without bleeding
Varices of other sites
Ecchymosis
Gastroesophageal laceration—hemorrhage syndrome
Esophgael hemorrhage
Gastric-Duodenal ulcer disease
Angiodysplasia of stomach and duodenum with hemorrhage
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PTT……..con’t
537.84
556.0–557.9
562.02–562.03
562.12
562.13
568.81
569.3
570
571.0–573.9
576.0–576.9
577.0
578.0–578.9
579.0–579.9
581.0–581.9
583.9
584.5–584.9
585.4
585.5
585.6
585.9
586
593.81–593.89
596.7
596.81
596.82
596.83
596.89
599.70-599.72
607.82
608.83
611.89
620.7
621.4
622.8
623.6
623.8
624.5
626.6
626.7
627.0
627.1
629.0
632
634.00–634.92
635.10–635.12
636.10–636.12
637.10–637.12
85730
Dieulafoy lesion (hemorrhagic) of stomach and duodenum
Hemorrhagic bowel disease
Diverticulosis of small intestine with hemorrhage
Diverticulosis of colon with hemorrhage
Diverticulitis of colon without hemorrhage
Hemoperitoneum (nontraumatic)
Hemorrhage of rectum and anus
Acute and subacute necrosis of liver
Liver disease (in place of specific codes listed)
Biliary tract disorders
Acute pancreatitis
Gastrointestinal Hemorrhage
Malabsorption
Nephrotic Syndrome
Nephritis, with unspecified pathological lesion in kidney
Acute Renal Failure
Chronic kidney disease, Stage IV (severe)
Chronic kidney disease, Stage V
End stage renal disease
Chronic kidney disease, unspecified
Renal failure
Other disorders of kidney and ureter, with hemorrhage
Hemorrhage into bladder wall
Infection of cystostomy
Mechanical complication of cystostomy
Other complication of cystostomy
Other specified disorders of bladder
Hematuria
Penile hemorrhage
Vascular disorders of male genital organs
Other specified disorders of breast, including hematoma
Hemorrhage of broad ligament
Hematometra
Other specified disorders of cervix, with hemorrhage
Vaginal hematoma
Other specified diseases of the vagina, with hemorrhage
Hematoma of vulva
Metrorrhagia
Postcoital bleeding
Premenopausal bleeding
Postmenopausal bleeding
Hematocele female not elsewhere classified
Missed abortion
Spontaneous abortion
Legally induced abortion, complicated by delayed or excessive hemorrhage
Illegally induced abortion, complicated by delayed or excessive hemorrhage
Abortion unspecified, complicated by delayed or excessive hemorrhage
PeaceHealth Laboratories | Medicare Coverage Policies
71
PTT……..con’t
638.1
639.1
639.6
640.00–640.93
641.00–641.93
642.00–642.94
646.70–646.73
649.30-649.34
649.50
649.51
649.53
656.00–656.03
658.40–658.43
666.00–666.34
671.20–671.54
673.00–673.84
674.30–674.34
710.0
713.2
713.6
719.10–719.19
729.5
729.81
733.10-733.19
762.1
764.90–764.99
767.0–767.11
767.8
770.3
772.0–772.9
774.0–774.7
776.0–776.9
780.2
782.4
782.7
784.7
784.8
785.4
785.50
786.05
786.30-786.39
85730
Failed attempt abortion, complicated by delayed or excessive hemorrhage
Delayed or excessive hemorrhage following abortion and ectopic and molar
pregnancies
Complications following abortion and ectopic and molar pregnancies, embolism
Hemorrhage in early pregnancy
Antepartum hemorrhage
Hypertension complicating pregnancy, childbirth, and the puerperium
Liver disorders in pregnancy
Coagulation defects complicating pregnancy, childbirth, or the puerperium
Spotting complicating pregnancy, unspecified as to episode of care or not
applicable
Spotting complicating pregnancy, delivered, with or without mention of
antepartum condition
Spotting complicating pregnancy, antepartum condition or complication
Fetal maternal hemorrhage
Infection of amniotic cavity
Postpartum hemorrhage
Phlebitis in pregnancy
Obstetrical pulmonary embolus
Other complications of surgical wounds, with hemorrhage
Systemic Lupus erythematosus
Arthropathy associated with hematologic disorders (note: may not be used
without indicating associated condition first)
Arthropathy associated with Henoch Schoenlein (note: may not be used without
indicating associated condition first)
Hemarthrosis
Leg pain/calf pain
Swelling of limb
Pathologic fracture associated with fat embolism
Other forms of placental separation with hemorrhage (affecting newborn code
do not assign to mother's record)
Fetal intrauterine growth retardation
Subdural and cerebral hemorrhage
Other specified birth trauma, with hemorrhage
Fetal and newborn pulmonary hemorrhage
Fetal and neonatal hemorrhage
Other perinatal jaundice
Hemorrhagic disease of the newborn
Syncope
Jaundice, unspecified, not of newborn
Spontaneous ecchymoses Petechiae
Epistaxis
Hemorrhage from throat
Gangrene
Shock
Shortness of breath
Hemoptysis
PeaceHealth Laboratories | Medicare Coverage Policies
72
PTT……..con’t
786.50
786.59
789.00–789.09
789.7
790.92
800.00–800.99
801.00–801.99
802.20–802.9
803.00–803.99
804.00–804.99
805.00–806.9
807.00–807.09
807.10–807.19
808.8–808.9
809.0–809.1
810.00–810.13
811.00–811.19
812.00–812.59
813.10–813.18
813.30–813.33
813.50–813.54
813.90–813.93
819.0–819.1
820.00–821.39
823.00–823.92
827.0–829.1
852.00–853.19
860.0–860.5
861.00–861.32
862.0–862.9
863.0–863.99
864.00–864.19
865.00–865.19
866.00–866.13
867.0–867.9
868.00–868.19
869.0–869.1
900.00–900.9
901.0–901.9
902.0–902.9
903.00–903.9
904.0–904.9
920—924.9
925.1–929.9
958.2
959.9
85730
Chest pain, unspecified
Chest pain
Abdominal pain
Colic
Abnormal coagulation profile
Fracture of vault of skull
Fracture of base of skull
Fracture of face bones
Other fracture, skull
Multiple fractures, skull
Fracture, vertebral column
Fractures of rib(s), closed
Fracture of rib(s), open
Fracture of pelvis
Fracture of trunk
Fracture of clavicle
Fracture of scapula
Fracture of humerus
Fracture of radius and ulna, upper end, open
Fracture of radius and ulna, shaft, open
Fracture of radius and ulna, lower end, open
Fracture of radius and ulna, unspecified part, open
Multiple fractures
Femur
Tibia and fibula
Other multiple lower limb
Subarachnoid subdural, and extradural hemorrhage, following injury, Other and
specified intracranial hemorrhage following injury
Traumatic pneumothorax and hemothorax
Injury to heart and lung
Injury to other and unspecified intrathoracic organs
Injury to gastrointestinal tract
Injury to liver
Injury to spleen
Injury to kidney
Injury to pelvic organs
Injury to other intra-abdominal organs
Internal injury to unspecified or ill defined organs
Injury to blood vessels of head and neck
Injury to blood vessels of the thorax
Injury to blood vessels of the abdomen and pelvis
Injury to blood vessels of upper extremity
Injury to blood vessels of lower extremity and unspecified sites
Contusion with intact skin surface
Crushing injury
Secondary and recurrent hemorrhage
Injury, unspecified site
PeaceHealth Laboratories | Medicare Coverage Policies
73
PTT……..(con’t)
964.2
964.5
964.7
980.0
989.5
995.20
995.21
995.24
995.27
995.29
996.70-996.79
997.02
998.11
998.12
999.2
V12.3
V58.2
V58.61
V58.83
85730
Poisoning by anticoagulants
Poisoning by anticoagulant antagonists
Poisoning by natural blood and blood products
Toxic effects of alcohol
Snake venom
Unspecified adverse effect of unspecified drug, medicinal and biological
substance
Arthus phenomenon
Failed moderate sedation during procedure
Other drug allergy
Unspecified adverse effect of other drug, medicinal and biological substance
Other complications of internal prosthetic device
Iatrogenic cerbrovascular infarction or hemorrhage
Hemorrhage or hematoma complicating a procedure
Hematoma complicating a procedure
Other vascular complications of medical care
Personal history of diseases of blood and blood forming organs
Admission for Transfusion of blood products
Long term (current use) of anticoagulants
Encounter for therapeutic drug monitoring
PeaceHealth Laboratories | Medicare Coverage Policies
74
Prostate Specific Antigen (PSA), Total
Policy Type: NCD (National
Coverage Decision)
CPT CODE(S)
84153
ICD-9 CODES
185
188.5
196.5
196.6
196.8
198.5
198.82
233.4
236.5
239.5
596.0
599.60
599.69
599.70-599.72
600.00
600.01
600.10
600.11
600.21
601.9
602.9
788.20
788.21
788.30
788.41
788.43
788.62
788.63
788.64
788.65
790.93
793.6/793.7
794.9
V10.46
TEST NAME
Prostate Specific Antigen (PSA), total
ICD-9 DESCRIPTIONS
Malignant neoplasm of prostate
Malignant neoplasm of bladder neck
Secondary malignant neoplasm, lymph nodes inguinal region and lower limb
Secondary malignant neoplasm, intrapelvic lymph nodes
Secondary malignant neoplasm, lymph nodes of multiple sites
Secondary malignant neoplasm, bone and bone marrow
Secondary malignant neoplasm, genital organs
Carcinoma in situ, prostate
Neoplasm of uncertain behavior of prostate
Neoplasm of unspecified nature, other genitourinary organs
Bladder neck obstruction
Urinary obstruction, unspecified
Urinary obstruction, not elsewhere classified
Hematuria
Hypertrophy (benign) of prostate without urinary obstruction and other lower
urinary tract symptoms (LUTS)
Benign prostate hypertrophy with urinary obstruction
Nodular prostate without urinary obstruction
Nodular prostate with urinary obstruction
Benign localized hyperplasia of prostate with urinary obstruction and other
lower urinary tract symptoms (LUTS)
Unspecified prostatitis
Unspecified disorder of prostate
Retention of urine, unspecified
Incomplete bladder emptying
Urinary incontinence, unspecified
Urinary frequency
Nocturia
Slowing of urinary stream
Urgency of urination
Urinary hesitancy
Straining on urination
Elevated prostate specific antigen
Non-specific abnormal result of radiologic examination, evidence of malignancy
Bone scan evidence of malignancy
Personal history of malignant neoplasm; prostate
PeaceHealth Laboratories | Medicare Coverage Policies
75
Prothrombin Time
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
85610
ICD-9 CODES
002.0—002.9
003.0—003.9
038.9
042
060.0—060.9
065.0–065.9
070.0–070.9
075
078.6
078.7
084.8
120.0
121.1
121.3
124
134.2
135
152.0–152.9
155.0–155.2
156.0–156.9
157.0–157.9
188.0–189.9
197.7
198.0
198.1
200.00–200.88
202.00–202.98
209.20-209.27,
209.29
209.70
209.71
209.72
209.73
209.74
209.75
209.79
223.0–223.9
238.4
238.5
TEST NAME
Prothrombin Time
ICD-9 DESCRIPTIONS
Typhoid and paratyphoid
Other Salmonella infections
Unspecified Septicemia
Human Immunodeficiency virus (HIV) disease
Yellow fever
Arthropod-borne hemorrhagic fever
Viral hepatitis
Infectious mononucleosis
Hemorrhagic nephrosonephritis
Arenaviral hemorrhagic fever
Blackwater fever
Schistosomiasis
Clonorchiasos
Fascioliasis
Trichinosis
Hirudiniasis
Sarcoidosis
Malignant neoplasm of small intestine, including duodenum
Malignant neoplasm of liver and intrahepatic bile ducts
Malignant neoplasm of gallbladder and extrahepatic bile ducts
Malignant neoplasm of pancreas
Malignant neoplasm of bladder, kidney, and other and unspecified urinary
organs
Secondary malignant neoplasm, liver
Secondary malignant neoplasm, kidney
Secondary malignant neoplasm, other urinary organs
Lymphosarcoma and reticulosarcoma
Nodular and other Lymphomas
Malignant carcinoid tumors of other and unspecified sites
Secondary neuroendocrine tumor, unspecified site
Secondary neuroendocrine tumor of distant lymph nodes
Secondary neuroendocrine tumor of liver
Secondary neuroendocrine tumor of bone
Secondary neuroendocrine tumor of peritoneum
Secondary Merkel cell carcinoma
Secondary neuroendocrine tumor of other sites
Benign neoplasm of kidney and other urinary organs
Polycythemia vera
Histocytic and mast cells—neoplasm of uncertain behavior
PeaceHealth Laboratories | Medicare Coverage Policies
76
PT………..con’t
238.6
238.71-238.79
239.4
239.5
239.9
246.3
249.40
249.41
250.40–250.43
263.0–263.9
269.0
269.2
273.0–273.9
275.01-275.09
277.1
277.30-277.39
280.0
280.9
281.0
281.1
281.9
285.0
285.1
286.0–286.9
287.0–287.9
289.81
290.40–290.43
325
342.90–342.92
360.43
362.18
362.30–362.37
362.43
362.81
363.61–363.72
368.9
372.72
374.81
376.32
377.42
377.53
377.62
377.72
379.23
380.31
386.2
386.50
85610
Plasma cells—neoplasm of uncertain behavior
Lymphatic and hematoppoietic tissues
Neoplasm of unspecified nature, bladder
Neoplasm of unspecified nature, other genitourinary organs
Neoplasm of unspecified nature, site unspecified
Hemorrhage and infarction of thyroid
Secondary diabetes mellitus with renal manifestations, not uncontrolled
Secondary diabetes mellitus with renal manifestations, uncontrolled
Diabetic with renal manifestations
Other and unspecified protein/calorie malnutrition
Deficiency of Vitamin K
Unspecified vitamin deficiency
Disorders of plasma protein metabolism
Disorders of iron metabolism
Disorders of porphyrin metabolism
Amyloidosis
Iron deficiency anemia, secondary to blood loss—chronic
Iron deficiency anemia, unspecified
Pernicious anemia
Other Vitamin B12 Deficiency Anemia, NEC
Unspecified Deficiency Anemia, NOS
Sideroblastic anemia
Acute posthemorrhagic anemia
Coagulation defects
Purpura and other hemorrhagic conditions
Primary hypercoagulable state
Arteriosclerotic dementia
Phlebitis and thrombophlebitis of intracranial venous sinuses
Hemiplegia NOS
Hemophthalmios, except current injury
Retinal vasculitis
Retinal vascular occlusion
Hemorrhagic detachment of retnal pigment epithelium
Retinal hemorrhage
Choroidal hemorrhage and rupture, detachment
Unspecified Visual Disturbances
Conjunctival hemorrhage
Hemorrhage of eyelid
Orbital hemorrhage
Hemorrhage in optic nerve sheaths
Disorders of optic chiasm associated with vascular disorders
Disorders of visual pathways associated with vascular disorders
Disorders of visual cortex associated with vascular disorders
Vitreous hemorrhage
Hematoma of auricle or pinna
Vertigo of central origin
Labyrinthine dysfunction, unspecified
PeaceHealth Laboratories | Medicare Coverage Policies
77
PT………..con’t
394.0–394.9
395.0
395.2
396.0–396.9
397.0–397.9
398.0–398.99
403.01, 403.11,
403.91
404.02, 404.12,
404.92
410.00–410.92
411.1
411.81
411.89
413.0–413.9
414.00–414.07
414.3
414.4
414.8
414.9
415.0–415.19
416.9
423.0
424.0
424.1
424.90
425.0–425.9
427.0–427.9
428.0–428.9
429.0–429.4
429.79
430
431
432.0–432.9
433.00–433.91
434.00–434.91
435.0–435.9
436
437.0
437.1
437.6
440.0–440.9
441.0–441.9
443.0–443.9
444.01, 444.09,
444.1-444.9
447.1
85610
Diseases of the mitral valve
Rheumatic aortic stenosis
Rheumatic aortic stenosis with insufficiency
Diseases of mitral and aortic valves
Diseases of other endocardial structures
Other rheumatic heart disease
Hypertensive kidney disease with chronic kidney disease
Hypertensive heart and kidney disease with chronic kidney disease
Acute myocardial infarction
Intermediate coronary syndrome
Coronary occlusion without myocardial infarction
Other acute and subacute forms of ischemic heart disease
Angina pectoris
Coronary atherosclerosis
Coronary atherosclerosis due to lipid rich plaque
Coronary atherosclerosis due to calcified coronary lesion
Other specified forms of chronic ischemic heart disease
Chronic ischemic heart disease, unspecified
Acute pulmonary heart disease
Chronic pulmonary heart disease, unspecified
Hemopericardium
Mitral valve disorders
Aortic valve disorder
Endocarditis, valve unspecified, unspecified cause
Cardiomyopathy
Cardiac dysrhythmias
Heart failure
Ill-defined descriptions and complications of heart disease
Other certain sequelae of myocardial infarction, not elsewhere classified
Subarachnoid hemorrhage
Intracerebral hemorrhage
Other and unspecified intracranial hemorrhage
Occlusion and stenosis of precerebral arteries
Occlusion of cerebral arteries
Transient cerebral ischemia
Acute, but ill-defined cerebrovascular disease
Cerebral atherosclerosis
Other generalized ischemic cerebrovascular disease
Nonpyogenic thrombosis of intracranial venous sinus
Atherosclerosis
Aortic aneurysm and dissection
Other peripheral vascular disease
Arterial embolism and thrombosis
Stricture of artery
PeaceHealth Laboratories | Medicare Coverage Policies
78
PT………..con’t
447.2
447.6
448.0
448.9
451.0–451.9
452
453.0–453.9
455.2
455.5
455.8
456.0–456.1
456.8
459.0
459.10-459.19
459.2
459.81
459.89
511.81-511.89
514
530.7
530.82
530.86
530.87
531.00–535.71
555.0–555.9
556.0–556.9
557.0–557.9
562.02—562.03
562.10
562.11
562.12
562.13
568.81
569.3
571.0–571.9
572.2
572.4
572.8
573.1–573.9
576.0–576.9
577.0
578.0–578.9
579.0–579.9
581.0–581.9
583.9
584.5–584.9
85610
Rupture of artery
Arteritis, unspecified
Hereditary hemorrhagic telangiectasia
Other and unspecified capillary diseases
Phlebitis and thrombophlebitis
Portal vein thrombosis
Other venous embolism and thrombosis
Internal hemorrhoids with other complication
External hemorrhoids with other complication
Unspecified hemorrhoids with other complication
Esophageal varices
Varices of other sites
Hemorrhage, unspecified
Postphlebitis syndrome
Compression of vein
Venous (peripheral) insufficiency, unspecified
Other, other specified disorders of circulatory system
Other specified forms of effusion, except tuberculosis
Pulmonary congestion and hypostasis
Gastroesophageal laceration—hemorrhage syndrome
Esophageal hemorrhage
Infection of esophagostomy
Mechanical complication of esophagostomy
Gastric ulcer, duodenal ulcer, peptic ulcer, gastrojejunal ulcer, gastritis and
duodenitis
Regional enteritis
Ulcerative colitis
Vascular insufficiency of intestine
Diverticulosis of small intestine with hemorrhage
Diverticulosis of colon w/o hemorrhage
Diverticulitis of colon w/o hemorrhage
Diverticulosis of colon with hemorrhage
Diverticulitis of colon with hemorrhage
Hemoperitoneum (nontraumatic)
Hemorrhage of rectum and anus
Chronic liver disease and cirrhosis
Hepatic coma
Hepatorenal syndrome
Other sequelae of chronic liver disease
Hepatitis in viral diseases, other and unspecified disorder of liver
Other disorders of Biliary tract
Acute pancreatitis
Gastrointestinal hemorrhage
Intestinal Malabsorption
Nephrotic Syndrome
Nephritis, with unspecified pathological lesion in kidney
Acute Renal Failure
PeaceHealth Laboratories | Medicare Coverage Policies
79
PT………..con’t
585.4
585.5
585.6
585.9
586
593.81–593.89
596.7
585.4
585.5
585.6
585.9
586
593.81–593.89
596.7
596.81
596.82
596.83
596.89
599.70-599.72
607.82
608.83
611.89
620.7
621.4
622.8
623.6
623.8
624.5
626.2–626.9
627.0
627.1
629.0
632
634.10–634.12
635.10–635.12
636.10–636.12
637.10–637.12
638.1
639.1
639.6
640.00–640.93
641.00–641.93
642.00–642.94
646.70–646.73
649.30-649.34
85610
Chronic kidney disease, Stage IV (severe)
Chronic kidney disease, Stage V
End stage renal disease
Chronic kidney disease, unspecified
Renal failure, unspecified
Other specified disorders of kidney and ureter
Hemorrhage into bladder wall
Chronic kidney disease, Stage IV (severe)
Chronic kidney disease, Stage V
End stage renal disease
Chronic kidney disease, unspecified
Renal failure, unspecified
Other specified disorders of kidney and ureter
Hemorrhage into bladder wall
Infection of cystostomy
Mechanical complication of cystostomy
Other complication of cystostomy
Other specified disorders of bladder
Hematuria
Vascular disorders of penis
Vascular disorders of male genital organs
Other specified disorders of breast, including hematoma
Hemorrhage of broad ligament
Hematometra
Other specified noninflammatory disorders of cervix
Vaginal hematoma
Other specified noninflammatory disorders of the vagina
Hematoma of vulva
Abnormal bleeding from female genital tract
Premenopausal menorrhagia
Postmenopausal bleeding
Hematocele female, not classified elsewhere
Missed abortion
Spontaneous abortion, complicated by excessive hemorrhage
Legally induced abortion, complicated by delayed or excessive hemorrhage
Illegally induced abortion, complicated by delayed or excessive hemorrhage
Abortion unspecified, complicated by delayed or excessive hemorrhage
Failed attempted abortion, complicated by delayed or excessive hemorrhage
Delayed or excessive hemorrhage following abortion and ectopic and molar
pregnancies
Complications following abortion and ectopic and molar pregnancies with
embolism
Hemorrhage in early pregnancy
Antepartum hemorrhage, abruptio placentae, and placenta previa
Hypertension complicating pregnancy, childbirth, and the puerperium
Liver disorders in pregnancy
Coagulation defects complicating pregnancy, childbirth, or the puerperium
PeaceHealth Laboratories | Medicare Coverage Policies
80
PT………..con’t
649.50-649.53
656.00–656.03
658.40–658.43
666.00–666.34
671.20–671.94
673.00–673.84
674.30–674.34
713.2
713.6
719.15
719.16
719.19
729.5
729.81
733.10
746.00–746.9
762.1
767.0, 767.11
767.8
770.3
772.0–772.9
774.6
776.0–776.9
780.2
782.3
782.4
782.7
784.7
784.8
785.4
785.50
786.05
786.30-786.39
786.50
786.51
786.59
789.00–789.09
789.1
789.51
789.59
789.7
790.92
790.94
791.2
794.8
800.00–800.99
801.00–801.99
85610
Spotting complicating pregnancy
Fetal maternal hemorrhage
Infection of amniotic cavity
Postpartum hemorrhage
Venous complications in pregnancy and the puerperium
Obstetrical pulmonary embolism
Other complications of obstetrical surgical wounds
Arthropathy associated with hematological disorders
Arthropathy associated with hypersensitivity reaction
Hemarthrosis pelvic region and thigh
Lower leg
Multiple sites
Pain in limb
Swelling of limb
Patholgic fracture, unspecified site
Other Congenital anomalies of heart
Other forms of placental separation and hemorrhage
Birth trauma, subdural and cerebral hemorrhage and injury to scalp
Other specified birth trauma
Pulmonary hemorrhage
Fetal and neonatal hemorrhage
Unspecified fetal and neonatal jaundice
Hemorrhagic disease of the newborn
Syncope and collapse
Edema
Jaundice, unspecified, not of newborn
Spontaneous ecchymosis
Epistaxis
Hemorrhage from throat
Gangrene
Shock without mention of trauma
Shortness of breath
Hemoptysis
Chest pain, no other symptoms
Precordial pain
Chest pain, other
Abdominal pain
Hepatomegaly
Malignant ascites
Other ascites
Colic
Abnormal coagulation profile
Euthyroid sick syndrome
Hemoglobinuria
Abnormal Liver Function Study
Fracture of vault of skull
Fracture of base of skull
PeaceHealth Laboratories | Medicare Coverage Policies
81
PT………..con’t
802.20–802.9
803.00–803.99
804.00–804.99
805.00–806.9
807.00–807.09
807.10–807.19
808.8–808.9
809.0–809.1
810.00–810.13
811.00–811.19
812.00–812.59
813.10–813.18
813.30–813.33
813.50–813.54
813.90–813.93
819.0–819.1
820.00–821.39
823.00–823.92
827.0–829.1
852.00–853.19
860.0–860.5
861.00–861.32
862.0–862.9
863.0–863.99
864.00–864.19
865.00–865.19
866.00–866.13
867.0–867.9
868.00–868.19
869.0–869.1
900.00–900.9
901.0–901.9
902.0–902.9
903.00–903.9
904.0–904.9
920–924.9
925.1–929.9
958.2
959.9
964.0–964.9
980.0–980.9
981
982.0–982.8
987.0–987.9
989.0–989.9
85610
Fracture of face bones
Other and unqualified skull fractures
Multiple fractures involving skull or face with other bones
Fracture, vertebral column
Fractures of rib(s), closed
Fracture of rib(s), open
Fracture of Pelvis
Ill-defined fractures of bones of Trunk
Fracture of Clavicle
Fracture of Scapula
Fracture of Humerus
Fracture of radius and ulna, upper end, open
Shaft, open
Lower end, open
Fracture unspecified part, open
Multiple fractures involving both upper limbs, closed and open
Fracture of neck of femur
Fracture of tibia and fibula
Other multiple lower limb
Subarachnoid, subdural, and extradural hemorrhage, following injury, other and
specified intracranial hemorrhage following injury.
Traumatic pneumothorax and hemothorax
Injury to heart and lung
Injury to other and unspecified intrathoracic organs
Injury to gastrointestinal tract
Injury to liver
Injury to spleen
Injury to kidney
Injury to pelvic organs
Injury to other intra-abdominal organs
Internal injury to unspecified or ill defined organs
Injury to blood vessels of head and neck
Injury to blood vessels of the thorax
Injury to blood vessels of the abdomen and pelvis
Injury to blood vessels of upper extremity
Injury to blood vessels of lower extremity and unspecified sites
Contusion with intact skin surface
Crushing injury
Secondary and recurrent hemorrhage
Injury, unspecified site
Poisoning by agents primarily affecting blood constituents
Toxic effect of alcohol
Toxic effect of petroleum products
Toxic effects of solvents other than petroleum-based
Toxic effect of other gases, fumes or vapors
Toxic effect of other substances chiefly non-medicinal as to source
PeaceHealth Laboratories | Medicare Coverage Policies
82
PT………..con’t
995.20
995.21
995.24
995.27
995.29
996.82
997.02
997.41
997.49
998.11–998.12
999.2
999.80
999.83
999.84
999.85
999.89
V08
V12.1
V12.3
V12.50–V12.55,
V12.59
V15.1
V15.21-V15.29
V42.0
V42.1
V42.2
V42.6
V42.7
V42.81-V42.89
V43.21
V43.22
V43.3
V43.4
V58.2
V58.61
V58.83
85610
Unspecified adverse effect of unspecified drug, medicinal and biological
substance
Arthus phenomenon
Failed moderate sedation during procedure
Other drug allergy
Unspecified adverse effect of other drug, medicinal and biological substance
Complication of transplanted liver
Iatrogenic cerbrovascular infarction or hemorrhage
Retained cholelithiasis following cholecystectomy
Other digestive system complications
Hemorrhage or hematoma complicating a procedure
Other vascular complications
Transfusion reaction, unspecified
Hemolytic transfusion reaction, incompatibility unspecified
Acute hemolytic transfusion reaction, incompatibility unspecified
Delayed hemolytic transfusion reaction, incompatibility unspecified
Other transfusion reaction
Asymptomatic HIV infection
History of nutritional deficiency
Personal history of diseases of blood and blood-forming organs
Personal history of transient ischemic attack, cerebral infarction, or pulmonary
embolism without residual deficits
Personal history of surgery to heart and great vessels
Personal history of surgery of other major organs
Kidney replaced by transplant
Heart replaced by transplant
Heart valve replaced by transplant
Lung replaced by transplant
Liver replaced by transplant
Other specified organ or tissue replaced by transplant
Heart assist device
Fully implantable artificial heart
Heart valve replaced by other means
Blood vessel replaced by other means
Transfusion of blood products
Long-term (current) use of anticoagulants
Encounter for therapeutic drug monitoring
PeaceHealth Laboratories | Medicare Coverage Policies
83
Sexually Transmitted
Infections (STI’s)
Includes the following:
1) 86631, 86332, 87110, 87270, 87320, 87490, 87491, 87810, 87800* Chlamydia
2) 87590, 87591, 87850, 87800* Gonorrhea
3) 86592, 86593, 86780 Syphilis
4) 87340, 87341 Hepatitis B (Hepatitis B surface antigen)
*87800 Used for combined Chlamydia & Gonorrhea testing
Policy Type: NCD (National Coverage Decision)
Item/Service Description
Sexually transmitted infections (STIs) are infections that are passed from one person to another through
sexual contact. STIs remain an important cause of morbidity in the United States and have both health
and economic consequences. Many of the complications of STIs are borne by women and children
Often, STIs do not present any symptoms so can go untreated for long periods of time The presence of
an STI during pregnancy may result in significant health complications for the woman and infant. In fact,
any person who has an STI may develop health complications. Screening tests for the STIs in this
national coverage determination (NCD) are laboratory tests.
Under §1861(ddd) of the Social Security Act (the Act), the Centers for Medicare & Medicaid Services
(CMS) has the authority to add coverage of additional preventive services if certain statutory
requirements are met. The regulations provide: 410.64 Additional preventative services
(a) Medicare Part B pays for additional preventive services not described in paragraph (1) or (3) of the
definition of “preventive services” under §410.2, that identify medical conditions or risk factors for
individuals if the Secretary determines through the national coverage determination process (as defined
in section 1869(f)(1)(B) of the Act) that these services are all of the following: (1) reasonable and
necessary for the prevention or early detection of illness or disability.(2) recommended with a grade of
A or B by the United States Preventive Services Task Force, (3) appropriate for individuals entitled to
benefits under Part A or enrolled under Part B.
(b) In making determinations under paragraph (a) of this section regarding the coverage of a new
preventive service, the Secretary may conduct an assessment of the relation between predicted
outcomes and the expenditures for such services and may take into account the results of such an
assessment in making such national coverage determinations.
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STI’s……con’t
The scope of the national coverage analysis for this NCD evaluated the evidence for the following
STIs and high intensity behavioral counseling (HIBC) to prevent STIs for which the United States
Preventive Services Task Force (USPSTF) has issued either an A or B recommendation:
• Screening for chlamydial infection for all sexually active non-pregnant young women aged
24 and younger and for older non-pregnant women who are at increased risk,
• Screening for chlamydial infection for all pregnant women aged 24 and younger and for
older pregnant women who are at increased risk,
• Screening for gonorrhea infection in all sexually active women, including those who are
pregnant, if they are at increased risk,
• Screening for syphilis infection for all pregnant women and for all persons at increased risk,
•
•
Screening for hepatitis B viris (HBV) infection in pregnant women at their first prenatal
visit.
HIBC for the prevention of STI’s for all sexually active adolescents, and for adults at
increased risk for STI’s.
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Pursuant to Section 1861(ddd) of the Social Security Act, CMS may add coverage of “additional
preventive services” through the National Coverage Determination (NCD) process. The preventive
services must be:
1. Reasonable and necessary for the prevention or early detection of illness or disability;
2. Recommended with a grade of A or B by the United States Preventive Services Task Force (USPSTF);
and
3. Appropriate for individuals entitled to benefits under Part A or enrolled under Part B.
CMS reviewed the USPSTF recommendations and supporting evidence for screening for STIs and
HIBC to prevent STIs and determined that the criteria listed above were met, enabling CMS to cover
these preventive services. Therefore, effective November 8, 2011, CMS will cover screening for the
indicated STIs and HIBC to prevent STIs. The covered screening lab tests must be ordered by the
primary care provider. The HIBC must be provided by primary care providers in primary care settings
such as by the beneficiary’s family practice physician, internal medicine physician, or nurse
practitioner (NP) in the doctor’s office.
A new Healthcare Common Procedure Coding System (HCPCS) code, G0445 (high-intensity
behavioral counseling to prevent sexually transmitted infections, face-to-face, individual, includes:
education, skills training, and guidance on how to change sexual behavior, performed semi-annually,
30 minutes), has been created for use when reporting HIBC to prevent STIs, effective November 8,
2011. This code is included in the January 2012 Medicare Physician Fee Schedule Database (MPFSDB)
and Integrated Outpatient Code Editor (IOCE) updates.
This code may be paid on the same date of service as an annual wellness visit (AWV), evaluation and
management (E&M) code, or during the global billing period for obstetrical care, but only one G0445
may be paid on any one date of service. If billed on the same date of service with an E&M code, the
E&M code should have a distinct diagnosis code other than the diagnosis code used to indicate
high/increased risk for STIs for the G0445 service. An E&M code should not be billed when the sole
reason for the visit is HIBC to prevent STIs.
The use of the correct diagnosis code(s) on the claims is imperative to identify these services as
preventive services and to show that the services were provided within the guidelines for
coverage as preventive services. The patient’s medical record must clearly support the
diagnosis of high/increased risk for STIs and clearly reflect the components of the HIBC service
provided – education, skills training, and guidance on how to change sexual behavior - as
required for coverage.
The appropriate screening diagnosis code (ICD-9-CM V74.5 (screening bacterial – sexually
transmitted) or V73.89 (screening, disease or disorder, viral, specified type NEC)), when used with the
screening lab tests identified by Change Request (CR) 7610, will indicate that the test is a screening
test covered by Medicare. Diagnosis code V69.8 (other problems related to life style) is used to
indicate that the beneficiary is at high/increased risk for STIs. Providers should also use V69.8 for
sexually active adolescents when billing G0445 counseling services.
Diagnosis codes V22.0 (supervision of normal first pregnancy), V22.1 (supervision of other normal
pregnancy), or V23.9 (supervision of unspecified high-risk pregnancy) are also to be used when
appropriate. For services provided on an annual basis, this is defined as a 12-month period.
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CMS will cover screening for Chlamydia (86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810,
87800 (used for combined Chlamydia and gonorrhea testing), gonorrhea (87590, 87591, 87850, 87800
(used for combined Chlamydia and gonorrhea testing), syphilis (86592, 86593, 86780), and hepatitis B
(hepatitis B surface antigen) 87340, 87341)) with the appropriate FDA approved/cleared laboratory tests,
used consistent with FDA-approved labeling and in compliance with the CLIA regulations, when ordered
by the primary care provider, and performed by an eligible Medicare provider for these services. As per
the requirements, the presence of V74.5 or V73.89 and V69.8, denoting STI screening and high-risk
behavior, respectively, and/or V22.0, V22.1, or V23.9, denoting pregnancy as appropriate, must also be
present on the claim for STI services along with one of the procedure codes above.
Coverage for HIBC
CMS will also cover up to two, individual, 20- to 30-minute, face-to-face counseling sessions annually for
Medicare beneficiaries for HIBC to prevent STIs (G0445) for all sexually active adolescents and for adults
at increased risk for STIs (V69.8), if referred for this service by a primary care provider and provided by a
Medicare eligible primary care provider in a primary care setting. HIBC is defined as a program intended
to promote sexual risk reduction or risk avoidance which includes each of these broad topics, allowing
flexibility for appropriate patient-focused elements:
• Education;
• Skills training; and,
• Guidance on how to change sexual behavior.
The high/increased risk individual sexual behaviors, based on the USPSTF guidelines, include any of the
following:
• Multiple sex partners;
• Using barrier protection inconsistently;
• Having sex under the influence of alcohol or drugs;
• Having sex in exchange for money or drugs;
• Age (24 years of age or younger and sexually active for women for chlamydia and gonorrhea);
• Having an STI within the past year;
• IV drug use (hepatitis B only); and,
• In addition, for men – men having sex with men (MSM) and engaged in high-risk sexual behavior, but
no regard to age.
Community social factors such as high prevalence of STIs in the community populations should also be
considered in determining high/increased risk for chlamydia, gonorrhea, syphilis, and in recommending
HIBC.
High/increased risk sexual behavior for STIs is determined by the primary care provider by assessing the
patient’s sexual history which is part of any complete medical history, typically part of an AWV or
prenatal visit and considered in the development of a comprehensive prevention plan. The medical
record should be a reflection of the service provided.
For the purposes of this NCD, a primary care setting is defined as the provision of integrated, accessible
health care services by clinicians who are accountable for addressing a large majority of sonal health
care needs, developing a sustained partnership with patients, and practicing in the context of family and
community. Emergency departments, inpatient hospital settings, ambulatory surgical centers
(ASCs), independent diagnostic testing facilities, skilled nursing facilities (SNFs), inpatient
rehabilitation facilities, clinics providing a limited focus of health care services, and hospice are
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STI’s……con’t
Con’t…
examples of settings not considered primary care settings under this definition.
Billing Reminders
• Institutional providers should note that coverage requires services be performed in a primary care
setting. Consequently, if STI services are billed on Types of Bill (TOB) other than 13X, 14X and 85X
(when the revenue code on the 85X is not 096X, 097X, or 098X), OR, if G0445 is submitted on a TOB
other than 13X, 71X, 77X, or 85X, payment for the services will be denied using the following:
• Claim Adjustment Reason Code (CARC) 170 – “Payment is denied when performed/billed by this
type of provider. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110
Service Payment Information REF), if present.”
• Remittance Advice Remark Code (RARC) N428 – “This service was denied because Medicare only
covers this service in certain settings.”
• When applying frequency limitations to HIBC services, contractors will allow both a claim for the
professional service and a claim for the facility fee. Institutional claims may be identified as facility
Coverage fee claims for screening services if they contain G0445, and TOB 13X or TOB 85X (when the
revenue code is not 096X, 097X, or 098X). All other claims should be identified as professional service
claims for HIBC services (professional claims, and institutional claims with TOB 71X or 77X, or 85X
when the revenue code is 096X, 097X, or 098X.
• Contractors will allow institutional claims, TOBs 71X and 77X, to submit additional revenue lines on
claims with G0445. Also, HCPCS G0445 will not pay separately with another encounter/visit on the
same day for TOBs 71X and 77X with the exception of: initial preventive physical claims, claims
containing modifier 59, and 77X claims containing diabetes self-management training and medical
nutrition therapy services. If HCPCS G0445 is present on revenue lines along with an encounter/visit
with the same line-item date of service, contractors will assign group code CO and reason code 97 –
“The benefit for this service is included in the payment/allowance for another service/procedure that
has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop
2110 Services Payment Information REF), if present.”
• G0445 on institutional claims in hospital outpatient departments (TOB 13X) are paid based on OPPS,
in critical access hospitals (TOB 85X, not equal to 096X, 097X, or 098X) based on reasonable cost.
HCPCS G0445 with revenue codes 096X, 097X, or 098X, when billed on TOB 85X Method II is paid
based on 115 percent of the lesser of the MPFS amount or submitted charge.
• Medicare will enforce the frequency requirement for STI services, as mentioned above. Medicare will
deny line items that exceed the coverage frequency requirements using the following:
• CARC 119 – “Benefit maximum for this period or occurrence has been reached.”
• RARC N362 – “The number of days or units of service exceeds our acceptable maximum.”
• Medicare will deny line items on claims submitted for screening for STIs if the claim lacks the
appropriate ICD-9-CM code as mentioned earlier. Such services will be denied payment using:
• CARC 50 – “These are non-covered services because this is not deemed a “medical necessity” by the
payer. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment
Information REF), if present.”
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•RARC N386 – “This decision was based on a National Coverage Determination (NCD), An NCD
provides a coverage determination as to whether a specific item or service is covered. A copy of this
policy is available at http://www.cms.gov/mcd/search.asp. If you do not have web access, you may
contact the contractor to request a copy of the NCD.”
• The presence of ICD-9 code V74.5 or V73.89 identifies STI laboratory tests as screening lab tests
payable under CR7610 rather than as diagnostic tests.
• Screening for STI’s must be ordered by a primary care setting, with one of the following specialty
codes:
• 01 – General Practice
• 08 – Family Practice
• 11 – Internal Medicine
• 16 – Obstetrics/Gynecology
• 37 – Pediatric Medicine
• 38 – Geriatric Medicine
• 42 – Certified Nurse Midwife
• 50 – Nurse Practitioner
• 89 – Certified Clinical Nurse Specialist
• 97 – Physician Assistant
• STI screenings ordered by other than the above types of providers will be denied payment when
submitted on professional claims using:
Coverage
• CARC 184 – “The prescribing/ordering provider is not eligible to prescribe/order the service billed.
Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment
Information REF), if present.”
• Medicare will deny line items for G0445 if performed by other than the above types of providers
when submitted on professional claims using: o CARC 185 – “The rendering provider is not eligible to
perform the service billed. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110
Service Payment Information REF), if present.”
• RARC N95 – “This provider type/provider specialty may not bill this service.”
• Claims for G0445 must be for services performed in the following Places of Service (POS):
• 11 – Physician Office;
• 22 – Outpatient Hospital;
• 49 – Independent Clinic; or
• 71 – State or local public health clinic.
• Medicare will deny line items for G0445 if the POS code is other than 11, 22, 49, or 71, using the
following:
• CARC 58 – “Treatment was deemed by the payer to have been rendered in an inappropriate or invalid
place of service. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service
Payment Information REF), if present.”
• RARC N428 – “Not covered when performed in this Place of Service.”
• Upon full implementation in Medicare systems on July 2, 2012, providers may submit eligibility
inquiries in order to identify the next eligible date that beneficiaries may receive these services.
• Until systems are implemented, contractors will hold institutional claims received before July 2, 2012,
with TOBs 13X, 71X, 77X, and 85X reporting HCPCS G0445, or TOBs 13X, 14X, and 85X, when the
revenue code is not 096X, 097X, or 098X, for STI services.
• Effective for dates of service on or after November 8, 2011, contractors will not apply deductible or
coinsurance to claim lines containing HCPCS G0445, HIBC services.
• Contractors will load HCPCS G0445 to their HCPCS file with an effective date of November 8, 2011.
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Thyroid Testing
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
84436
84439
84443
84479
TEST NAME
Thyroxine; total
Thyroxine; free
Thyroid stimulating hormone (TSH)
Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio
(THBR)
ICD-9 CODES
ICD-9 DESCRIPTIONS
017.50–017.56
183.0
193
194.8
198.89
220
226
227.3
234.8
237.4
239.7
240.0–240.9
241.0–241.9
242.00–242.91
243
244.0–244.9
245.0–245.9
246.0–246.9
249.00-249.01
249.10-249.11
249.20-249.21
249.30-249.31
249.40-249.41
249.50-249.51
249.60-249.61
249.70-249.71
249.80-249.81
249.90-249.91
250.00–250.93
252.1
253.1
253.2
253.3
253.4
253.7
255.2
Tuberculosis of the thyroid gland
Malignant neoplasm of ovary
Malignant neoplasm of thyroid gland
Malignant neoplasm of other endocrine glands and related structures, other
Secondary malignant neoplasm of the thyroid
Benign neoplasm of ovary
Benign neoplasm of thyroid gland
Benign neoplasm of pituitary gland and craniopharyngeal duct
Carcinoma in situ of other and unspecified sites
Neoplasm of uncertain behavior of other and unspecified endocrine glands
Neoplasm of unspecified nature, thyroid gland
Goiter specified and unspecified
Nontoxic nodular goiter
Thyrotoxicosis with or without goiter
Congenital hypothyroidism
Acquired hypothyroidism
Thyroiditis
Other disorders of thyroid
Secondary diabetes mellitus without mention of complication
Secondary diabetes mellitus with ketoacidosis
Secondary diabetes mellitus with hyperosmolarity
Secondary diabetes mellitus with other coma
Secondary diabetes mellitus with renal manifestations
Secondary diabetes mellitus with ophthalmic manifestations
Secondary diabetes mellitus with neurological manifestations
Secondary diabetes mellitus with peripheral circulatory disorders
Secondary diabetes mellitus with other specified manifestations
Secondary diabetes mellitus with unspecified complication
Diabetes mellitus
Hypoparathyroidism
Other and unspecified anterior pituitary hyper function
Panhypopituitarism
Pituitary dwarfism
Other anterior pituitary disorders
Iatrogenic pituitary disorders
Adrenogenital disorders
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Thyroid Testing……con’t
84436, 84439, 84443, 84479
255.41
Glucocorticoid deficiency
255.42
Mineralocorticoid deficiency
256.31-256.39
Ovarian failure
257.2
Testicular hypofunction
258.01–258.9
Polyglandular dysfunction
262
Malnutrition, severe
263.0–263.9
Malnutrition, other and unspecified
266.0
Ariboflavinosis
272.0
Pure hypercholesterolemia
272.2
Mixed hyperlipidemia
272.4
Other and unspecified hyperlipidemia
275.40–275.49
Calcium disorders
275.5
Hungry bone syndrome
276.0
Hyposmolality and/or hypernatremia
276.1
Hyposmolality and/or hyponatremia
278.3
Hypercarotinemia
279.41
Autoimmune lymphoproliferative syndrome
279.49
Autoimmune disease, not elsewhere classified
281.0
Pernicious anemia
281.9
Unspecified deficiency anemia
283.0
Autoimmune hemolytic anemia
285.9
Anemia, unspecified
290.0
Senile dementia, uncomplicated
290.10–290.13
Presenile dementia
290.20–290.21
Senile dementia with delusional or depressive features
290.3
Senile dementia with delirium
293.0–293.1
Delirium
293.81–293.89
Transient organic mental disorders
294.8
Other specified organic brain syndromes
296.00–296.99
Affective psychoses
297.0
Paranoid state, simple
297.1
Paranoia
297.9
Unspecified paranoid state
298.3
Acute paranoid reaction
300.00–300.09
Anxiety states
Agitation—other and unspecified special symptoms or syndromes, not
307.9
elsewhere classified
310.1
Organic personality syndrome
311
Depressive disorder, not elsewhere classified
327.00
Organic insomnia, unspecified
327.01
Insomnia due to medical condition classfied elsewhere
327.09
Other organic insomnia
327.29
Other organic sleep apnea
327.52
Sleep related leg cramp
327.8
Other organic sleep disorders
331.0–331.2
Alzheimer’s, pick’s disease, Senile degeneration of brain
331.83
Mild cognitive impairment, so stated
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Thyroid Testing……con’t
84436, 84439, 84443, 84479
333.1
Essential and other specified forms of tremor
333.99
Other extrapyramidao diseases and abnormal movement disorders
354.0
Carpal Tunnel syndrome
356.9
Idiopathic peripheral neuropathy, unspecified polyneuropathy
358.1
Myasthenic syndromes in diseases classified elsewhere
359.5
Myopathy in endocrine diseases classified elsewhere
359.9
Myopathy, unspecified
368.2
Diplopia
372.71
Conjunctival hyperemia
372.73
Conjunctival edema
374.41
Lid retraction or lag
374.82
Eyelid edema
376.21
Thyrotoxic exophthalmos
376.22
Exophthalmic ophthlmoplegia
376.30–376.31
Exophthalmic conditions, unspecified and constant
376.33–376.34
Orbital edema or congestion, intermittent exophthalmos
378.50–378.55
Paralytic strabismus
401.0–401.9
Essential hypertension
403.00–403.91
Hypertensive kidney disease
404.00–404.93
Hypertensive heart and kidney disease
423.9
Unspecified disease of pericardium
425.7
Nutritional and metabolic cardiomyopathy
427.0
Paroxysmal supraventricular tachycardia
427.2
Paroxysmal tachycardia, unspecified
427.31
Atrial fibrillation
427.89
Other specified cardiac dysrhythmia
427.9
Cardiac dysrhythmia, unspecified
428.0
Congestive heart failure, unspecified
428.1
Left heart failure
429.3
Cardiomegaly
511.9
Unspecified pleural effusion
518.81
Acute respiratory failure
529.8
Other specified conditions of the tongue
560.1
Paralytic ileus
564.00-564.09
Constipation
564.7
Megacolon, other than Hirschsprung’s
568.82
Peritoneal effusion (chronic)
625.3
Dysmenorrhea
626.0–626.2
Disorders of menstruation
626.4
Irregular menstrual cycle
Other current conditions in the mother, classifiable elsewhere, but complicating
648.10–648.14
pregnancy, childbirth, or the puerperium, thyroid dysfunction
676.20–676.24
Engorgement of breast associated with childbirth and disorders of lactation
698.9
Unspecified pruritic disorder
701.1
Keratoderma, acquired (dry skin)
703.8
Other specified diseases of nail (Brittle nails)
704.00–704.09
Alopecia
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Thyroid Testing……con’t
84436, 84439, 84443, 84479
709.01
Vitiligo
710.0–710.9
Diffuse disease of connective tissue
728.2
Muscle wasting
728.87
Muscle weakness (generalized)
728.9
Unspecified disorder of muscle, ligament, and fascia
729.1
Myalgia and myositis, unspecified
729.82
Musculoskeletal cramp
730.30–730.39
Periostitis without osteomyelitis
733.02
Idiopathic osteoporosis
733.09
Osteoporosis, drug induced
750.15
Macroglossia, congenital
759.2
Anomaly of other endocrine glands
780.01
Coma
780.02
Transient alteration of awareness
780.09
Alteration of consciousness, other
780.50–780.52
Insomnia
780.60-780.66
Fever
780.71–780.79
Malaise and fatigue
780.8
Hyperhidrosis
780.93
Memory loss
780.94
Early satiety
780.96
Generalized pain
780.97
Altered mental status
780.99
Other general symptoms
781.0
Abnormal involuntary movements
781.3
Lack of coordination, ataxia
782.0
Disturbance of skin sensation
782.3
Localized edema
782.8
Changes in skin texture
782.9
Other symptoms involving skin and integumentary tissues
783.0
Anorexia
783.1
Abnormal weight gain
783.21
Abnormal loss of weight
783.6
Polyphagia
784.1
Throat pain
784.42
Dysphonia
784.43
Hypernasality
784.44
Hyponasality
784.49
Other voice and resonance disorders
784.51
Dysarthria
784.59
Other speech disturbance
785.0
Tachycardia, unspecified
785.1
Palpitations
785.9
Other symptoms involving cardiovascular system
786.09
Other symptoms involving respiratory system
786.1
Stridor
787.20–787.29
Dysphagia
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Thyroid Testing……con’t
84436, 84439, 84443, 84479
787.91–787.99
Other symptoms involving digestive system
789.51
Malignant ascites
789.59
Other ascites
Other nonspecific (abnormal) findings on radiological and other examination of
793.99
body structure
794.5
Thyroid, abnormal scan or uptake
796.1
Other nonspecific abnormal findings, abnormal reflex
799.21
Nervousness
799.22
Irritability
799.23
Impulsiveness
799.24
Emotional lability
799.25
Demoralization and apathy
799.29
Other signs and symptoms involving emotional state
990
Effects of radiation, unspecified
V10.87
Personal history of malignant neoplasm of the thyroid
V10.88
Personal history of malignant neoplasm of other endocrine gland
V10.91
Personal history of malignant neuroendocrine tumor
V12.21
Personal history of gestational diabetes
V12.29
Personal history of other endocrine, metabolic, and immunity disorders
V58.69
Long term (current) use of other medications
V67.00-V67.9
Follow-up examination
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Urinalysis
Policy # L33034
Policy Type: LCD (Local Coverage Decision)
CPT CODE(S)
81000
81001
81002
81003
81005
81007
81015
81020
TEST NAME
Urinalysis non-auto w/scope
Urinalysis auto w/scope
Urinalysis non-auto w/o scope
Urinalysis auto w/o scope
Urinalysis
Urine screen for bacteria
Microscopic exam of urine
Urinalysis glass test
ICD-9 CODES
ICD-9 DESCRIPTIONS
016.00-016.06
016.10-016.16
016.20-016.26
016.30-016.36
016.40-016.46
016.50-016.56
016.60-016.66
016.70-016.76
016.90-016.96
038.0-038.9
Tuberculosis of kidney
Tuberculosis of bladder
Tuberculosis of ureter
Tuberculosis of other urinary organs
Tuberculosis of epididymis
Tuberculosis of other male genital organs
Tuberculous oophoritis and salpingitis
Tuberculosis of other female genital organs
Unspecified genitourinary tuberculosis
Septicemia
Streptococcus infection in conditions classified elsewhere and of unspecified
site
Staphylococcus
Pneumococcus infection in conditions classified elsewhere and of unspecified
site
Klebsiella pneumoniae
E. Coli
Hemophilus influenzae (H. Influenzae) infection in conditions classified
elsewhere and of unspecified site
Proteus (Mirabilis) (Morganii) infection in conditions classified elsewhere and of
unspecified site
Pseudomonas infection in conditions classified elsewhere and of unspecified
site
Other specified bacterial infections
Helicobacter pylori [H. Pylori]
Other specified bacterial infections in conditions classified elsewhere and of
unspecified site other specified bacteria
Bacterial infection unspecified in conditions classified elsewhere and of
unspecified site
Genital herpes
041.00-041.09
041.10-041.19
041.2
041.3
041.41-041.49
041.5
041.6
041.7
041.81-041.85
041.86
041.89
041.9
054.10-054.19
070.0-070.59, 070.70,
070.71
072.0
078.11
Hepatitis
Mumps orchitis
Condyloma acuminatum
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81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
078.88
079.81
079.82
079.88
079.89
079.98
087.0
087.1
095.4
098.0-098.39, 098.89
099.3
099.40
099.41
099.49
099.53
099.54
100.0
102.0
102.1
102.2
102.3
102.4
102.5
102.6
102.7
102.8
102.9
112.1
112.2
125.0
125.1
131.00
131.01
131.02
131.03
135
185
186.0
186.9
187.1
187.2
187.3
187.5
187.6
187.7
Other specified diseases due to chlamydiae
Hantaviris infection
Sars-associated coronavirus infection
Other specified chlamydial infection
Other specified viral infection
Unspecified chlamydial infection
Relapsing fever louse-borne
Relapsing fever tick-borne
Syphilis of kidney
Gonococcal infection
Reiter’s disease
Other non-gonococcal urethritis unspecified
Other non-gonococcal urethritis chlamydia trachomatis
Other non-gonococcal urethritis other specified organism
Other venereal diseases due to chlamydia trachomatis lower genitourinary sites
Other venereal diseases due to chlamydia trachomatis other genitourinary sites
Leptospirosis icterohemorrhagica
Initial lesions of yaws
Multiple papillomata due to yaws and wet crab yaws
Other early skin lesions of yaws
Hyperkeratosis due to yaws
Gummata and ulcers due to yaws
Gangosa
Bone and joint lesions due to yaws
Other manifestations of yaws
Latent yaws
Yaws unspecified
Candidiasis of vulva and vagina
Candidiasis of other urogenital sites
Bancroftian filariasis
Mayalan filariasis
Urogenital trichomoniasis unspecified
Trichomonal vulvovaginitis
Trichomonal urethritis
Trichomonal prostatitis
Sarcoidosis
Malignant neoplasm of prostate
Malignant neoplasm of undescended testis
Malignant neoplasm of other and unspecified testis
Malignant neoplasm of prepuce
Malignant neoplasm of glans penis
Malignant neoplasm of body of penis
Malignant neoplasm of epididymis
Malignant neoplasm of spermatic cord
Malignant neoplasm of scrotum
PeaceHealth Laboratories | Medicare Coverage Policies
96
Urinalysis……con’t
187.8
188.0
188.1
188.2
188.3
188.4
188.5
188.6
188.7
188.8
188.9
189.0
189.1
189.2
189.3
189.4
189.8
189.9
198.0
198.1
203.00
203.01
203.02
222.2
223.0
223.1
223.2
223.3
223.81
223.89
233.4
233.7
233.9
236.5
236.7
236.90
236.91
236.99
249.00-249.91
250.00-250.93
253.5
253.6
271.4
272.2
272.3
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Malignant neoplasm of other specified sites of male genital organs
Malignant neoplasm of trigone or urinary bladder
Malignant neoplasm of dome of urinary bladder
Malignant neoplasm of lateral wall of urinary bladder
Malignant neoplasm of anterior wall of urinary bladder
Malignant neoplasm of posterior wall of urinary bladder
Malignant neoplasm of bladder neck
Malignant neoplasm of ureteric orifice
Malignant neoplasm of urachus
Malignant neoplasm of other specified sites of bladder
Malignant neoplasm of bladder part unspecified
Malignant neoplasm of kidney except pelvis
Malignant neoplasm of renal pelvis
Malignant neoplasm of ureter
Malignant neoplasm of urethra
Malignant neoplasm of paraurethral glands
Malignant neoplasm of other specified sites of urinary organs
Malignant neoplasm of urinary organ site unspecified
Secondary malignant neoplasm of kidney
Secondary malignant neoplasm of other urinary organs
Multiple myeloma, without mention of having achieved remission
Multiple myeloma in remission
Multiple myeloma, in relapse
Benign neoplasm of prostate
Benign neoplasm of kidney except pelvis
Benign neoplasm of renal pelvis
Benign neoplasm of ureter
Benign neoplasm of bladder
Benign neoplasm of urethra
Benign neoplasm of other specified sites of urinary organs
Carcinoma in situ of prostate
Carcinoma in situ of bladder
Carcinoma in situ of other and unspecified urinary organs
Neoplasm of uncertain behavior of prostate
Neoplasm of uncertain behavior of bladder
Neoplasm of uncertain behavior of urinary organ unspecified
Neoplasm of uncertain behavior of kidney and ureter
Neoplasm of uncertain behavior of other and unspecified urinary organs
Secondary diabetes mellitus
Diabetes
Diabetes insipidus
Other disorders of neurohypophysis
Renal glycosuria
Mixed hyperlipidemia
Hyperchylomicronemia
PeaceHealth Laboratories | Medicare Coverage Policies
97
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
272.4
273.0
273.1
273.2
273.3
273.4
273.8
274.00
274.01
274.02
274.03
274.10
274.11
274.19
275.01
275.02
275.03
275.09
275.42
276.0
276.1
276.2
276.3
276.4
276.50
276.51
276.52
276.61
276.69
276.8
276.9
277.00-277.09
277.1
277.2
277.30
277.31
277.39
277.4
277.5
277.88
282.60
282.61
282.62
282.63
282.64
Other and unspecified hyperlipidemia
Polyclonal hypergammaglobulinemia
Monoclonal paraproteinemia
Other paraproteinemias
Macroglobulinemia
Alpha-1-antitrypsin deficiency
Other disorders of plasma protein metabolism
Gouty arthropathy, unspecified
Acute gouty arthropathy
Chronic gouty arthropathy without mention of tophus (tophi)
Chronic gouty arthropathy with tophus (tophi)
Gouty nephropathy unspecified
Uric acid nephrolithiasis
Other gouty nephropathy
Hereditary hemochromatosis
Hemochromatosis due to repeated red blood cell transfusions
Other hemochromatosis
Other disorders of iron metabolism
Hypercalcemia
Hyperosmolality and/or hypernatremia
Hyposmolality and/or hyponatremia
Acidosis
Alkalosis
Mixed acid-base balance disorder
Volume depletion, unspecified
Dehydration
Hypovolemia
Transfusion associated circulatory overload
Other fluid overload
Hypopotassemia
Electrolyte and fluid disorders not elsewhere classified
Cystic fibrosis
Disorders of porphyrin metabolism
Other disorders of purine and pyrimidine metabolism
Amyloidosis, unspecified
Familial Mediterranean fever
Other amyloidosis
Disorders of bilirubin excretion
Mucopolysaccharidosis
Tumor lysis syndrome
Sickle-cell disease unspecified
HB-SS disease without crisis
HB-SS disease with crisis
Sickle-cell/HB-C disease without crisis
Sickle-cell/HB-C disease with crisis
PeaceHealth Laboratories | Medicare Coverage Policies
98
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
282.68
282.69
283.11
283.2
287.41
287.49
306.53
310.1
344.61
401.0
401.1
401.9
402.00
402.01
402.10
402.11
402.90
402.91
403.00
403.01
403.10
403.11
403.90
403.91
404.00-404.93
405.01
405.09
405.11
405.19
405.91
405.99
421.0
421.1
421.9
428.0
446.0
446.1
446.20
446.21
Other sickle-cell disease without crisis
Other sickle-cell disease with crisis
Hemolytic-uremic syndrome
Hemoglobinuria due to hemolysis from external causes
Post-transfusion purpura
Other secondary thrombocytopenia
Psychogenic dysuria
Personality change due to conditions classified elsewhere
Cauda equina syndrome with neurogenic bladder
Malignant essential hypertension
Benign essential hypertension
Unspecified essential hypertension
Malignant hypertensive heart disease without heart failure
Malignant hypertensive heart disease with heart failure
Benign hypertensive heart disease without heart failure
Benign hypertensive heart disease with heart failure
Unspecified hypertensive heart disease without heart failure
Unspecified hypertensive heart disease with heart failure
Hypertensive chronic kidney disease, malignant, with chronic kidney disease
Stage I through Stage IV, or unspecified
Hypertensive chronic kidney disease, malignant, with chronic kidney disease
Stage V or end stage renal disease
Hypertensive chronic kidney disease, benign, with chronic kidney disease Stage I
through Stage IV, or unspecified
Hypertensive chronic kidney disease, benign, with chronic kidney disease Stage
V or end stage renal disease
Hypertensive chronic kidney disease, unspecified, with chronic kidney disease
Stage I through Stage IV, or unspecified
Hypertensive chronic kidney disease, unspecified, with chronic kidney disease
Stage V or end stage renal disease
Hypertensive heart and chronic kidney disease
Malignant renovascular hypertension
Other malignant secondary hypertension
Benign renovascular hypertension
Other benign secondary hypertension
Unspecified renovascular hypertension
Other unspecified secondary hypertension
Acute & subacute bacterial endocarditis
Acute & subacute infective endocarditis in diseases classified elsewhere
Acute endocarditis unspecified
Congestive heart failure unspecified
Polyarteritis nodosa
Acute febrile mucocutaneous lymph node syndrome (MCLS)
Hypersensitivity angiitis unspecified
Goodpasture’s syndrome
PeaceHealth Laboratories | Medicare Coverage Policies
99
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
446.29
446.3
446.4
446.5
446.6
446.7
447.3
447.4
447.5
447.6
456.4
457.0
457.1
570
571.40
571.41
571.42
571.49
571.5
571.6
571.8
572.2
573.0
573.1
573.2
573.3
580.0-580.9
581.0-581.9
582.0-582.9
583.0-583.9
584.5-584.9
585.1-585.9
586
587
588.0
588.1
588.81
588.89
589.0
589.1
589.9
590.00-590.11
590.2
590.3
590.80
Other specified hypersensitivity angiitis
Lethal midline granuloma
Wegener’s granulomatosis
Giant cell arteritis
Thrombotic microangiopathy
Takayasu’s disease
Hyperplasia of renal artery
Celiac artery compression syndrome
Necrosis of artery
Arteritis unspecified
Scrotal varices
Postmasectomy lymphedema syndrome
Other lymphedema
Acute and subacute necrosis of liver
Chronic hepatitis unspecified
Chronic persistent hepatitis
Autoimmune hepatitis
Other chronic hepatitis
Cirrhosis of liver without alcohol
Biliary cirrhosis
Other chronic non-alcoholic liver disease
Hepatic encephalopathy
Chronic passive congestion of liver
Hepatitis in viral diseases classified elsewhere
Hepatitis in other infectious diseases classified elsewhere
Hepatitis unspecified
Acute glomerulonephritis
Nephrotic syndrome
Chronic glomerulonephritis
Nephritis and nephropathy not specified as acute or chronic
Acute kidney failure
Chronic kidney disease
Renal failure unspecified
Renal sclerosis unspecified
Renal osteodystrophy
Nephrogenic diabetes insipidus
Secondary hyperparathyroidism (of renal origin)
Other specified disorders resulting from impaired renal function
Unilateral small kidney
Bilateral small kidneys
Small kidney unspecified
Chronic/Acute pyelonephritis
Renal and perinephric abscess
Pyeloureteritis cystica
Pyelonephritis unspecified
PeaceHealth Laboratories | Medicare Coverage Policies
100
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
590.81
590.9
591
592.0
592.1
592.9
593.0
593.1
593.2
593.3
593.4
593.5
593.6
593.70-593.73
593.81
593.82
593.89
593.9
594.0
594.1
594.2
594.8
594.9
595.0-595.9
596.0
596.1
596.2
596.3
596.4
596.51
596.52
596.53
596.54
596.55
596.59
596.6
596.7
596.81
596.82
596.83
596.89
596.9
597.0
597.80
597.81
Pyelitis or pyelonephritis in diseases classified elsewhere
Infection of kidney unspecified
Hydronephrosis
Calculus of kidney
Calculus of ureter
Urinary calculus unspecified
Nephroptosis
Hyperthrophy of kidney
Cyst of kidney acquired
Stricture or kinking of ureter
Other ureteric obstruction
Hydroureter
Postural proteinuria
Vesicoureteral reflux
Vascular disorders of kidney
Ureteral fistula
Other specified disorders of kidney and ureter
Unspecified disorder of kidney and ureter
Calculus in diverticulum of bladder
Other calculus in bladder
Calculus in urethra
Other lower urinary tract calculus
Calculus of lower urinary tract unspecified
Cystitis
Bladder neck obstruction
Intestinovesical fistula
Vesical fistula not elsewhere classified
Diverticulum of bladder
Atony of bladder
Hypertonicity of bladder
Low bladder compliance
Paralysis of bladder
Neurogenic bladder NOS
Detrusor sphincter dyssynergia
Other functional disorder of bladder
Rupture of bladder non-traumatic
Hemorrhage into bladder wall
Infection of cystostomy
Mechanical complication of cystostomy
Other complication of cystostomy
Other specified disorders of bladder
Unspecified disorder of bladder
Urethral abscess
Urethritis unspecified
Urethral syndrome NOS
PeaceHealth Laboratories | Medicare Coverage Policies
101
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
597.89
598.00
598.01
598.1
598.2
598.8
598.9
599.0
599.1
599.2
599.3
599.4
599.5
599.60
599.69
599.70
599.71
599.72
599.81
599.82
599.83
599.84
599.89
599.9
600.01
600.11
600.21
600.91
601.0
601.1
601.2
601.3
601.4
601.8
601.9
602.0
602.1
602.2
602.3
602.8
602.9
603.0
Other urethritis
Urethral structure due to unspecified infection
Urethral structure due to infective diseases classified elsewhere
Traumatic urethral stricture
Post-operative urethral stricture
Other specified causes of urethral stricture
Urethral stricture unspecified
Urinary tract infection site not specified
Urethral fistula
Urethral diverticulum
Urethral caruncle
Urethral false passage
Prolapsed urethral mucosa
Urinary obstruction, unspecified
Urinary obstruction, not elsewhere classified
Hematuria unspecified
Gross hematuria
Microscopic hematuria
Urethral hypermobility
Intrinsic (urethral) sphincter deficiency (ISD)
Urethral instability
Other specified disorders of urethra
Other specified disorders of urinary tract
Unspecified disorder of urethra and urinary tract
Hypertrophy (benign) of prostate with urinary obstruction and other lower
urinary tract symptoms (LUTS)
Nodular prostate with urinary obstruction
Benign localized hyperplasia of prostate with urinary obstruction and other
lower urinary tract symptoms (LUTS)
Hyperplasia of prostate, unspecified, with urinary obstruction and other lower
urinary symptoms (LUTS)
Acute prostatitis
Chronic prostatitis
Abscess of prostate
Prostatocystitis
Prostatitis in diseases classified elsewhere
Other specified inflammatory diseases of prostate
Prostatitis unspecified
Calculus of prostate
Congestion or hemorrhage of prostate
Atrophy of prostate
Dysplasia of prostate
Other specified disorders of prostate
Unspecified disorder of prostate
Encysted hydrocele
PeaceHealth Laboratories | Medicare Coverage Policies
102
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
603.1
603.8
603.9
604.0
604.90
604.91
605
606.1
606.9
607.1
607.81
607.84
607.89
608.0
608.1
608.23
608.24
608.83
608.89
608.9
616.10
616.11
618.00
618.01
618.02
618.03
618.04
618.05
618.09
619.0
619.1
619.2
619.8
619.9
625.0
625.6
625.70
625.71
625.79
625.9
628.9
629.31
629.32
634.00-634.32
Infected hydrocele
Other specified types of hydrocele
Hydrocele unspecified
Orchitis epididymitis and epididymo-orchitis with abscess
Orchitis and epididymitis unspecified
Orchitis and epididymitis in diseases classified elsewhere
Redundant prepuce and phimosis
Oligospermia
Male infertility unspecified
Balanoposthitis
Balanitis xerotica obliterans
Impotence of organic origin
Other specified disorders of penis
Seminal vesiculitis
Spermatocele
Torsion of appendix testis
Torsion of appendix epididymis
Vascular disorders of male genital organs
Other specified disorders of male genital organs
Unspecified disorder of male genital organs
Vaginitis and vulvovaginitis unspecified
Vaginitis and vulvovaginitis in diseases classified elsewhere
Unspecified prolapse of vaginal walls
Cystocele, midline
Cystocele, lateral
Urethrocele
Rectocele
Perineocele
Other prolapse of vaginal walls without mention of uterine prolapse
Urinary-genital tract fistula female
Digestive-genital tract fistula female
Genital tract-skin fistula female
Other specified fistulas involving female genital tract
Unspecified fistula involving female genital tract
Dyspareunia
Stress incontinence female
Vulvodynia, unspecified
Vulvar vestibulitis
Other vulvodynia
Unspecified symptom associated with female genital organs
Infertility female of unspecified origin
Erosion of implanted vaginal mesh and other prosthetic materials to
surrounding organ or tissue
Exposure of implanted vaginal mesh and other prosthetic materials into vagina
Spontaneous abortion
PeaceHealth Laboratories | Medicare Coverage Policies
103
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
635.00-635.32
636.00-636.32
637.00-637.32
638.0
638.1
638.2
638.3
639.0
639.1
639.2
639.3
642.00
642.01
642.02
642.03
642.04
642.10
642.11
642.12
642.13
642.14
642.20
642.21
642.22
642.23
642.24
642.30
642.31
642.32
642.33
642.34
642.40
642.41
642.42
642.43
642.44
642.50
642.51
Legally induced abortion
Illegal abortion
Unspecified abortion
Failed attempted abortion complicated by genital tract and pelvic infection
Failed attempted abortion complicated by delayed or excessive hemorrhage
Failed attempted abortion complicated by damage to pelvic organs or tissues
Failed attempted abortion complicated by renal failure
Genital tract and pelvic infection following abortion or ectopic and molar
pregnancies
Delayed or excessive hemorrhage following abortion or ectopic and molar
pregnancies
Damage to pelvic organs and tissues following abortion or ectopic and molar
pregnancies
Kidney failure following abortion and ectopic and molar pregnancies
Benign essential hypertension complicating pregnancy childbirth and the
puerperium unspecified as to episode of care
Benign essential hypertension with delivery
Benign essential hypertension with delivery with postpartum complication
Antepartum benign essential hypertension
Postpartum benign essential hypertension
Hypertension secondary to renal disease complicating pregnancy childbirth and
the puerperium unspecified as to episode of care
Hypertension secondary to renal disease with delivery
Hypertension secondary to renal disease with delivery with postpartum
complication
Hypertension secondary to renal disease antepartum
Hypertension secondary to renal disease postpartum
Other pre-existing hypertension complicating pregnancy childbirth and the
puerperium unspecified as to episode of care
Other pre-existing hypertension with delivery
Other pre-existing hypertension with delivery with postpartum complication
Other pre-existing hypertension antepartum
Other pre-existing hypertension postpartum
Transient hypertension of pregnancy unspecified as to episode of care
Transient hypertension of pregnancy with delivery
Transient hypertension of pregnancy with delivery with postpartum
complication
Antepartum transient hypertension
Postpartum transient hypertension
Mild or unspecified pre-eclampsia unspecified as to episode of care
Mild or unspecified pre-eclampsia with delivery
Mild or unspecified pre-eclampsia with delivery with postpartum complication
Mild or unspecified pre-eclampsia antepartum
Mild or unspecified pre-eclampsia postpartum
Severe pre-eclampsia unspecified as to episode of care
Severe pre-eclampsia with delivery
PeaceHealth Laboratories | Medicare Coverage Policies
104
Urinalysis……con’t
642.52
642.53
642.54
642.60
642.61
642.62
642.63
642.64
642.70
642.71
642.72
642.73
642.74
642.90
642.91
642.92
642.93
642.94
646.10
646.11
646.12
646.13
646.14
646.20
646.21
646.22
646.23
646.24
646.50
646.51
646.52
646.53
646.54
646.60
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Severe pre-eclampsia with delivery with postpartum complication
Severe pre-eclampsia antepartum
Severe pre-eclampsia postpartum
Eclampsia complicating pregnancy childbirth or the puerperium unspecified as
to episode of care
Eclampsia with delivery
Eclampsia with delivery with postpartum complication
Eclampsia antepartum
Eclampsia postpartum
Pre-eclampsia or eclampsia superimposed on pre-existing hypertension
complicating pregnancy childbirth or the puerperium unspecified as to episode
of care
Pre-eclampsia or eclampsia superimposed on pre-existing hypertension with
delivery
Pre-eclampsia or eclampsia superimposed on pre-existing hypertension with
delivery with postpartum complication
Pre-eclampsia or eclampsia superimposed on pre-existing hypertension
antepartum
Pre-eclampsia or eclampsia superimposed on pre-existing hypertension
postpartum
Unspecified hypertension complicating pregnancy, childbirth, or the puerperium
unspecified as to episode of care
Unspecified hypertension with delivery
Unspecified hypertension with delivery with postpartum complication
Unspecified antepartum hypertension
Unspecified postpartum hypertension
Edema or excessive weight gain in pregnancy unspecified as to episode of care
Edema or excessive weight gain in pregnancy with delivery with or without
antepartum complication
Edema or excessive weight gain in pregnancy with delivery with postpartum
complication
Antepartum edema or excessive weight gain
Postpartum edema or excessive weight gain
Unspecified renal disease in pregnancy unspecified as to episode of care
Unspecified renal disease in pregnancy with delivery
Unspecified renal disease in pregnancy with delivery with postpartum
complication
Unspecified antepartum renal disease
Unspecified postpartum renal disease
Asymptomatic bacteriuria in pregnancy unspecified as to episode of care
Asymptomatic bacteriuria in pregnancy with delivery
Asymptomatic bacteriuria in pregnancy with delivery with postpartum
complication
Antepartum asymptomatic bacteriuria
Postpartum asymptomatic bacteriuria
Infections of genitourinary tract in pregnancy unspecified as to episode of care
PeaceHealth Laboratories | Medicare Coverage Policies
105
Urinalysis……con’t
646.61
646.62
646.63
646.64
647.10
647.11
647.12
647.13
647.14
648.00
648.01
648.02
648.03
648.04
648.80
648.81
648.82
648.83
648.84
654.40
654.41
654.42
654.43
654.44
658.40
658.41
658.43
659.20
659.21
659.23
659.30
659.31
659.33
664.80
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Infections of genitourinary tract in pregnancy with delivery
Infections of genitourinary tract in pregnancy with delivery with postpartum
complication
Antepartum infections of genitourinary tract
Postpartum infections of genitourinary tract
Gonorrhea of mother complicating pregnancy, childbirth, or the puerperium;
unspecified as to episode of care
Gonorrhea of mother with delivery
Gonorrhea of mother with delivery with postpartum complication
Antepartum gonorrhea
Postpartum gonorrhea
Diabetes mellitus of mother complicating pregnancy, childbirth, or the
puerperium unspecified as to episode of care
Diabetes mellitus of mother with delivery
Diabetes mellitus of mother with delivery with postpartum complication
Antepartum diabetes mellitus
Postpartum diabetes mellitus
Abnormal glucose tolerance of mother complicating pregnancy, childbirth, or
the puerperium; unspecified as to episode of care
Abnormal glucose tolerance of mother with delivery
Abnormal glucose tolerance of mother with delivery with postpartum
complication
Abnormal glucose tolerance of mother antepartum
Abnormal glucose tolerance of mother postpartum
Other abnormalities in shape or position of gravid uterus and of neighboring
structures unspecified as to episode of care
Other abnormalities in shape or position of gravid uterus and of neighboring
structures delivered
Other abnormalities in shape or position of gravid uterus and of neighboring
structures delivered with postpartum complication
Other abnormalities in shape or position of gravid uterus and of neighboring
structures antepartum
Other abnormalities in shape or position of gravid uterus and of neighboring
structures postpartum
Infection of amniotic cavity unspecified as to episode of care
Infection of amniotic cavity delivered
Infection of amniotic cavity antepartum
Unspecified type maternal pyrexia during labor unspecified as to episode of
care
Unspecified type maternal pyrexia during labor delivered
Unspecified type maternal pyrexia antepartum
Generalized infection during labor unspecified as to episode of care
Generalized infection during labor delivered
Generalized infection during labor antepartum
Other specified trauma to perineum and vulva unspecified as to episode of care
in pregnancy
PeaceHealth Laboratories | Medicare Coverage Policies
106
Urinalysis……con’t
664.81
664.84
664.90
664.91
664.94
665.40
665.41
665.44
665.50
665.51
665.54
665.80
665.81
665.82
665.83
665.84
669.30
669.32
669.34
670.00
670.02
670.04
670.20
670.22
670.24
670.82
670.84
672.00
672.02
672.04
710.0
710.1
710.2
710.3
710.4
710.9
711.00-711.09
714.0
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Other specified trauma to perineum and vulva with delivery
Other specified trauma to perineum and vulva postpartum
Unspecififed trauma to perineum and vulva unspecified as to episode of care in
pregnancy
Unspecified trauma to perineum and vulva with delivery
Unspecified trauma to perineum and vulva postpartum
High vaginal laceration unspecified as to episode of care in pregnancy
High vaginal laceration with delivery
High vaginal laceration postpartum
Other injury to pelvic organs unspecified as to episode of care in pregnancy
Other injury to pelvic organs with delivery
Other injury to pelvic organs postpartum
Other specified obstetrical trauma unspecified as to episode of care
Other specified obstetrical trauma with delivery
Other specified obstetrical trauma delivered with postpartum condition or
complication
Other specified obstetrical trauma antepartum
Other specified obstetrical trauma postpartum
Acute kidney failure following labor and delivery, unspecified as to episode of
care or not applicable
Acute kidney failure following labor and delivery, delivered, with mention of
postpartum complication
Acute kidney failure following labor and delivery, postpartum condition or
complication
Major puerperal infection, unspecified, unspecified as to episode of care or not
applicable
Major puerperal infection, unspecified, delivered, with mention of postpartum
complication
Major puerperal infection, unspecified, postpartum condition or complication
Puerperal sepsis, unspecified as to episode of care or not applicable
Puerperal sepsis, delivered, with mention of postpartum complication
Puerperal sepsis, postpartum condition or complication
Other major puerperal infection, delivered, with mention of postpartum
complication
Other major puerperal infection, postpartum condition or complication
Puerperal pyrexia of unknown origin unspecified as to episode of care
Puerperal pyrexia of unknown origin delivered with postpartum complication
Puerperal pyrexia of unknown origin postpartum
Systemic lupus erythematosus
Systemic sclerosis
Sicca syndrome
Dermatomyositis
Polymyositis
Unspecified diffuse connective tissue disease
Pyogenic arthritis
Rheumatoid arthritis
PeaceHealth Laboratories | Medicare Coverage Policies
107
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
714.1
714.2
714.30
714.31
714.32
714.33
714.4
714.81
714.89
714.9
719.-40-719.49
724.2
724.5
752.51
753.0
753.10
753.11
753.12
753.13
753.14
753.15
753.16
753.17
753.19
753.3
753.4
753.5
753.6
753.7
753.8
753.9
780.02
780.09
780.2
780.33
780.4
780.60
780.61
780.62
780.63
780.64
780.65
780.66
780.79
780.91
Felty’s syndrome
Other rheumatoid arthritis with visceral or systemic involvement
Chronic or unspecified polyarticular juvenile rheumatoid arthritis
Acute polyarticular juvenile rheumatoid arthritis
Pauciarticular juvenile rheumatoid arthritis
Monoarticular juvenile rheumatoid arthritis
Chronic postrheumatic arthropathy
Rheumatoid lung
Other specified inflammatory polyarthropathies
Unspecified inflammatory polyarthropathy
Pain in joint
Lumbago
Backache unspecified
Undescended testis
Renal agenesis and dysgenesis
Cystic kidney disease unspecified
Congenital single renal cyst
Polycystic kidney unspecified type
Polycystic kidney autosomal dominant
Polycystic kidney autosomal recessive
Renal dysplasia
Medullary cystic kidney
Medullary sponge kidney
Other specified cystic kidney disease
Other specified anomalies of kidney
Other specified anomalies of ureter
Exstrophy of urinary bladder
Congenital atresia and stenosis of urethra and bladder neck
Congenital anomalies of urachus
Other specified congenital anomalies of bladder and urethra
Unspecified congenital anomaly of urinary system
Transient alteration of awareness
Alteration of consciousness other
Syncope and collapse
Post traumatic seizures
Dizziness and giddiness
Fever, unspecified
Fever presenting with conditions classified elsewhere
Post-procedural fever
Post-vaccination fever
Chills (without fever)
Hypothermia not associated with low environmental temperature
Febrile non-hemolytic transfusion reaction
Other malaise and fatigue
Fussy infant (baby)
PeaceHealth Laboratories | Medicare Coverage Policies
108
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
780.97
780.99
782.3
783.5
785.59
787.01
787.03
787.91
788.0
788.1
788.20
788.21
788.29
788.30
788.31
788.32
788.33
788.34
788.35
788.36
788.37
788.38
788.39
788.41
788.42
788.43
788.5
788.61
788.62
788.63
788.64
788.65
788.69
788.7
788.8
788.91
788.99
789.00-789.09
789.36
789.51
790.21
790.22
790.29
790.7
790.93
Altered mental status
Other general symptoms
Edema
Polydipsia
Other shock without trauma
Nausea with vomiting
Vomiting alone
Diarrhea
Renal colic
Dysuria
Retention of urine unspecified
Incomplete bladder emptying
Other specified retention of urine
Urinary incontinence unspecified
Urge incontinence
Stress incontinence male
Mixed incontinence (male) (female)
Incontinence without sensory awareness
Post-void dribbling
Nocturnal enuresis
Continuous leakage
Overflow incontinence
Other urinary incontinence
Urinary frequency
Polyuria
Nocturia
Oliguria and anuria
Splitting of urinary stream
Slowing of urinary stream
Urgency of urination
Urinary hesitancy
Straining on urination
Other abnormality of urinary stream
Urethral discharge
Extravasation of urine
Functional urinary incontinence
Other symptoms involving urinary system
Abdominal pain
Abdominal or pelvic swelling mass or lump epigastric
Malignant ascites
Impaired fasting glucose
Impaired glucose tolerance test (oral)
Other abnormal glucose
Bacteremia
Elevated prostate specific antigen (PSA)
PeaceHealth Laboratories | Medicare Coverage Policies
109
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
790.95
791.0
791.1
791.2
791.3
791.4
791.5
791.6
791.7
791.9
793.5
793.6
794.4
795.79
796.2
799.21
799.22
799.23
799.24
799.59
806.5
806.70
806.71
808.0
808.1
808.2
808.3
808.41
808.42
808.43
808.44
808.49
808.51
808.52
808.53
808.54
808.59
808.9
866.00
866.01
866.02
866.03
Elevated C-reactive protein (CRP)
Proteinuria
Chyluria
Hemoglobinuria
Myoglobinuria
Biliuria
Glycosuria
Acetonuria
Other cells and casts in urine
Other non-specific findings on examination of urine
Non-specific (abnormal) findings on radiological and other examination of
genitourinary organs
Non-specific (abnormal) findings on radiological and other examination of
abdominal area, including retroperitoneum
Non-specific abnormal results of function study of kidney
Other and unspecified non-specific immunological findings
Elevated blood pressure reading without diagnosis of hypertension
Nervousness
Irritability
Implusiveness
Emotional lability
Other signs and symptoms involving cognition
Open fracture of lumbar spine with spinal cord injury
Open fracture of sacrum and coccyx with unspecified spinal cord injury
Open fracture of sacrum and coccyx with complete cauda equina lesion
Closed fracture of acetabulum
Open fracture of acetabulum
Closed fracture of pubis
Open fracture of pubis
Closed fracture of ilium
Closed fracture of ischium
Multiple closed pelvic fractures with disruption of pelvic circle
Multiple closed pelvic fractures without disruption of pelvic circle
Closed fracture of other specified part of pelvis
Open fracture of ilium
Open fracture of ischium
Multiple open pelvic fractures with disruption of pelvic circle
Multiple open pelvic fractures without disruption of pelvic circle
Open fracture of other specified part of pelvis
Unspecified open fracture of pelvis
Unspecified injury to kidney without open wound into cavity
Hematoma of kidney without rupture of capsule without open wound into
cavity
Laceration of kidney without open wound into cavity
Complete disruption of kidney parenchyma without open wound into cavity
PeaceHealth Laboratories | Medicare Coverage Policies
110
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
866.10
866.11
866.12
866.13
867.0
867.1
867.2
867.3
867.6
867.7
867.8
867.9
868.00
868.09
868.10
868.19
869.0
869.1
876.1
878.0-878.7, 878.9
879.3,879.5,879.7879.9
922.1
922.2
922.31
922.32
922.33
922.4
926.0
926.11
926.12
926.19
926.8
927.00
928.00
928.01
928.10
928.8
929.0
929.9
939.0
939.2
Unspecified injury to kidney with open wound into cavity
Hematoma of kidney without rupture of capsule with open wound into cavity
Laceration of kidney with open wound into cavity
Complete disruption of kidney parenchyma with open wound into cavity
Injury to bladder and urethra without open wound into cavity
Injury to bladder and urethra with open wound into cavity
Injury to ureter without open wound into cavity
Injury to ureter with open wound into cavity
Injury to other specified pelvic organs without open wound into cavity
Injury to other specified pelvic organs with open wound into cavity
Injury to unspecified pelvic organ without open wound into cavity
Injury to unspecified pelvic organ with open wound into cavity
Injury to unspecified intra-abdominal organ without open wound into cavity
Injury to other and multiple intra-abdominal organs without open wound into
cavity
Injury to unspecified intra-abdominal organ with open wound into cavity
Injury to other and multiple intra-abdominal organs with open wound into
cavity
Internal injury to unspecified or ill-defined organs without open wound into
cavity
Internal injury to unspecified or ill-defined organs with open wound into cavity
Open wound of back complicated
Open wound of penis, scrotum and testes, vulva, or vagina
Open wound of abdominal wall, parts of trunk,& of unspecified site(s)
Contusion of chest wall
Contusion of abdominal wall
Contusion of back
Contusion of buttock
Contusion of interscapular region
Contusion of genital organs
Crushing injury of external genitalia
Crushing injury of back
Crushing injury of buttock
Crushing injury of other specified sites of trunk
Crushing injury of multiple sites of trunk
Crushing injury of shoulder region
Crushing injury of thigh
Crushing injury of hip
Crushing injury of lower leg
Crushing injury of multiple sites of lower limb
Crushing injury of multiple sites not elsewhere classified
Crushing injury of unspecified site
Foreign body in bladder and urethra
Foreign body in vulva and vagina
PeaceHealth Laboratories | Medicare Coverage Policies
111
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
939.3
939.9
941.39
941.49
941.59
942.20
942.22
942.23
942.24
942.29
942.30
942.32
942.33
942.34
942.39
942.40
942.42
942.43
942.44
942.49
942.50
942.52
942.53
942.54
942.59
943.30
Foreign body in penis
Foreign body in unspecified site in genitourinary tract
Full thickness skin loss due to burn (third degree NOS) of multiple sites (except
with eye) of face, head, and neck
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple
sites (except with eye) of face, head and neck without loss of a body part
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple
sites (except eye) of face, head, and neck with loss of a body part
Blisters with epidermal loss due to burn (second degree) of unspecified site of
trunk
Blisters with epidermal loss due to burn (second degree) of chest wall excluding
breast and nipple
Blisters with epidermal loss due to burn (second degree) of abdominal wall
Blisters with epidermal loss due to burn (second degree) of back (any part)
Blisters with epidermal loss due to burn (second degree) of other and multiple
sites of trunk
Full thickness skin loss due to burn (third degree NOS) of unspecified site of
trunk
Full thickness skin loss due to burn (third degree NOS) of chest wall excluding
breast and nipple
Full thickness skin loss due to burn (third degree NOS) of abdominal wall
Full thickness skin loss due to burn (third degree NOS) of back (any part)
Full thickness skin loss due to burn (third degree NOS) of other and multiple
sites of trunk
Deep necrosis of underlying tissues due to burn (deep third degree) of trunk
unspecified site without loss of body part
Deep necrosis of underlying tissues due to burn (deep third degree) of chest
wall excluding breast and nipple without loss of chest wall
Deep necrosis of underlying tissues due to burn (deep third degree) of
abdominal wall without loss of abdominal wall
Deep necrosis of underlying tissues due to burn (deep third degree) of back
(any part) without loss of back
Deep necrosis of underlying tissues due to burn (deep third degree) of other
and multiple sites of trunk without loss of body part
Deep necrosis of underlying tissues due to burn (deep third degree) of
unspecified site of trunk with loss of body part
Deep necrosis of underlying tissues due to burn (deep third degree) of chest
wall excluding breast and nipple with loss of chest wall
Deep necrosis of underlying tissues due to burn (deep third degree) of
abdominal wall with loss of abdominal wall
Deep necrosis of underlying tissues due to burn (deep third degree) of back
(any part) with loss of back
Deep necrosis of underlying tissues due to burn (deep third degree) of other
and multiple sites of trunk with loss of a body part
Full thickness skin loss due to burn (third degree NOS) of unspecified site of
upper limb
PeaceHealth Laboratories | Medicare Coverage Policies
112
Urinalysis……con’t
943.39
943.40
943.49
943.50
943.59
946.2
946.3
946.4
946.5
947.1
947.2
947.3
947.4
947.8
948.21-948.88,
948.90-948.99
949.3
949.4
949.5
958.5
959.11
959.12
959.13
959.14
959.19
961.2
963.1
963.3
965.1
992.0
992.1
992.2
992.3
992.4
992.5
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Full thickness skin loss due to burn (third degree NOS) of multiple sites of upper
limb except wrist and hand
Deep necrosis of underlying tissues due to burn (deep third degree) of
unspecified site of upper limb without loss of a body part
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple
sites of upper limb except wrist and hand without loss of upper limb
Deep necrosis of underlying tissues due to burn (deep third degree) of
unspecified site of upper limb with loss of a body part
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple
sites of upper limb except wrist and hand with loss of upper limb
Blisters with epidermal loss due to burn (second degree) of multiple specified
sites
Full thickness skin loss due to burn (third degree NOS) of multiple specified
sites
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple
specified sites without loss of a body part
Deep necrosis of underlying tissues due to burn (deep third degree) of multiple
specified sites with loss of a body part
Burn of larynx trachea and lung
Burn of esophagus
Burn of gastrointestinal tract
Burn of vagina and uterus
Burn of other specified sites of internal organs
Burn (any degree)
Full thickness skin loss due to burn (third degree NOS) unspecified site
Deep necrosis of underlying tissue due to burn (deep third degree) unspecified
site without loss of a body part
Deep necrosis of underlying tissues due to burn (deep third degree) unspecified
site with loss of a body part
Traumatic anuria
Other injury of chest wall
Other injury of abdomen
Fracture of corpus cavernosum penis
Other injury of external genitals
Other and unspecified injury of other sites of trunk
Poisoning by heavy metal anti-infectives
Poisoning by antineoplastic and immunosuppressive drugs
Poisoning by alkalizing agents
Poisoning by salicylates
Heat stroke and sunstroke
Heat syncope
Heat cramps
Heat exhaustion anhydrotic
Heat exhaustion due to salt depletion
Heat exhaustion unspecified
PeaceHealth Laboratories | Medicare Coverage Policies
113
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
992.6
992.7
992.8
995.20
995.21
995.22
995.23
995.27
995.29
995.53
995.54
995.59
996.30
996.31
996.32
996.39
996.62
996.64
996.65
996.76
996.81
997.5
998.00
998.01
998.02
998.09
998.2
999.32
999.33
999.34
999.60
999.61
999.62
999.63
999.69
999.70
999.71
999.72
999.73
Heat fatigue transient
Heat edema
Other specified heat effects
Unspecified adverse effect of unspecified drug, medicinal, and biological
substance
Arthus phenomenon
Unspecified adverse effect of anesthesia
Unspecified adverse effect of insulin
Other drug allergy
Unspecified adverse effect of other drug, medicinal, and biological substance
Child sex abuse
Child physical abuse
Other child abuse and neglect
Mechanical complication of unspecified genitourinary device implant and graft
Mechanical complication due to urethral (indwelling) catheter
Mechanical complication due to intrauterine contraceptive device
Other mechanical complication of genitourinary device implant and graft
Infection and inflammatory reaction due to other vascular device implant and
graft
Infection and inflammatory reaction due to indwelling urinary catheter
Infection and inflammatory reaction due to other genitourinary device implant
and graft
Other complications due to genitourinary device implant and graft
Complications of transplanted kidney
Urinary complications not elsewhere classified
Post-operative shock, unspecified
Post-operative shock, cardiogenic
Post-operative shock, septic
Post-operative shock, other
Accidental puncture or laceration during a procedure not elsewhere classified
Bloodstream infection due to central venous catheter
Local infection due to central venous catheter
Acute infection following transfusion, infusion, or injection, of blood and blood
products
ABO incompatibility reaction, unspecified
ABO incompatibility with hemolytic transfusion reaction not specified as acute
or delayed
ABO incompatibility with acute hemolytic transfusion reaction
ABO incompatibility with delayed hemolytic transfusion reaction
Other ABO incompatibility reaction
RH incompatibility reaction, unspecified
RH incompatibility with hemolytic transfusion reaction not specified as acute or
delayed
RH incompatibility with acute hemolytic transfusion reaction
RH incompatibility with delayed hemolytic transfusion reaction
PeaceHealth Laboratories | Medicare Coverage Policies
114
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Urinalysis……con’t
999.74
999.75
999.76
999.77
999.78
999.79
999.80
999.81
999.82
999.83
999.84
999.85
999.88
999.89
V10.46-V10.59
V13.00
V13.01
V13.02
V13.03
V13.09
V13.62
V15.51
V15.59
V21.0
V21.1
V21.2
V21.30
V21.31
V21.32
V21.33
V21.34
V21.35
V21.8
V21.9
V22.0
V22.1
V22.2
V23.0
V23.1
V23.2
V23.3
V23.41
V23.49
Other RH incompatibility reaction
Non-ABO incompatibility reaction, unspecified
Non-ABO incompatibility with hemolytic transfusion reaction not specified as
acute or delayed
Non-ABO incompatibility with acute hemolytic transfusion reaction
Non-ABO incompatibility with delayed hemolytic transfusion reaction
Other non-ABO incompatibility reaction
Transfusion reaction, unspecified
Extravasation of vesicant chemotherapy
Extravasation of other vesicant agent
Hemolytic transfusion reaction, incompatibility unspecified
Acute hemolytic transfusion reaction, incompatibility unspecified
Delayed hemolytic transfusion reaction, incompatibility unspecified
Other infusion reaction
Other transfusion reaction
Personal history of malignant neoplasm
Personal history of unspecified urinary disorder
Personal history of urinary calculi
Personal history, urinary (tract) infection
Personal history, nephrotic syndrome
Personal history of other specified urinary system disorders
Personal history of other (corrected) congenital malformations of genitourinary
system
Personal history of traumatic fracture
Personal history of other injury
Period of rapid growth in childhood
Puberty
Other development of adolescence
Unspecified low birth weight status
Low birth weight status less than 500 grams
Low birth weight status 500-999 grams
Low birth weight status 1000-1499 grams
Low birth weight status 1500-1999 grams
Low birth weight status 2000-2500 grams
Other specified constitutional states in development
Unspecified constitutional state in development
Supervision of normal first pregnancy
Supervision of other normal pregnancy
Pregnant state incidental
Supervision of high-risk pregnancy with history of infertility
Supervision of high-risk pregnancy with history of tropho blastic disease
Supervision of high-risk pregnancy with history of abortion
Supervision of high-risk pregnancy with grand multiparity
Supervision of high-risk pregnancy with history of pre-term labor
Supervision of high-risk pregnancy with other poor obstetric history
PeaceHealth Laboratories | Medicare Coverage Policies
115
Urinalysis……con’t
V23.5
V23.7
V23.81
V23.82
V23.83
V23.84
V23.89
V23.9
V42.0
V44.50
V44.51
V44.52
V44.59
V44.6
V45.11
V45.12
V58.0
V58.63
V58.64
V58.65
V58.69
V59.4
V67.51
V87.01
V87.09
V87.11
V87.12
V87.19
V87.2
V90.83
81000, 81001, 81002,
81003, 81005, 81007,
81015, 81020
Supervision of high-risk pregnancy with other poor reproductive history
Supervision of high-risk pregnancy with insufficient prenatal care
Supervision of high-risk pregnancy with elderly primigravida
Supervision of high-risk pregnancy with elderly multigravida
Supervision of high-risk pregnancy with young primigravida
Supervision of high-risk pregnancy with young multigravida
Supervision of other high-risk pregnancy
Supervision of unspecified high-risk pregnancy
Kidney replaced by transplant
Cystostomy unspecified
Cutaneous-vesicostomy
Appendico-vesicostomy
Other cystostomy
Status of other artificial opening of urinary tract
Renal dialysis status
Non-compliance with renal dialysis
Radiotherapy
Long-term (current) use of antiplatelets/antithrombotics
Long-term (current) us of non-steroidal anti-inflammatories
Long-term (current) use of steroids
Long-term (current) use of other medications
Kidney donors
Follow-up examination following completed treatment with high-risk
medication not elsewhere classified
Contact with and (suspected) exposure to arsenic
Contact with and (suspected) exposure to other hazardous metals
Contact with and (suspected) exposure to aromatic amines
Contact with and (suspected) exposure to benzene
Contact with and (suspected) exposure to other hazardous aromatic
compounds
Contact with and (suspected) exposure to other potentially hazardous chemicals
Retained stone or crystalline fragments
PeaceHealth Laboratories | Medicare Coverage Policies
116
Urine Culture, Bacterial/
Sensitivity Studies
Policy Type: NCD (National Coverage Decision)
CPT CODE(S)
87086
87088
87184
87186
ICD-9 CODES
003.1
038.0–038.9
276.2
276.4
286.6
288.00-288.09
288.8
306.53
306.59
518.82
570
580.0–580.9
583.0–583.9
585.6
590.00–590.9
592.0–592.9
593.0–593.9
594.0–594.9
595.0–595.9
597.0
597.80–597.89
598.00–598.01
599.0
599.70-599.72
600.00
600.01
600.10
600.11
600.20
600.21
600.90
600.91
601.0–601.9
602.0–602.9
TEST NAME
Culture, bacterial, urine; quantitative, colony count
Culture, bacterial; with isolation and presumptive identification of each
isolates, urine.
Sensitivity studies, antibiotic; disk method, per plate (12 or fewer disks)
Sensitivity studies, antibiotic; microtiter, minimum inhibitory
concentration (MIC), any number of antibiotics
ICD-9 DESCRIPTIONS
Salmonella Septicemia
Septicemia
Acidosis
Metabolic acidosis/alkalosis
Defibrination syndrome/disseminated intravascular coagulation
Neutropenia
Other specified disease of white blood cells including leukemoid reaction/leukocytosis
Psychogenic dysuria
Other psychogenic genitourinary malfunction
Other pulmonary insufficiency, not elsewhere classified
Acute and subacute necrosis of liver
Acute glomerulonephritis
Nephritis and Nephropathy, not specified as acute or chronic
End stage renal disease
Infections of kidney/pyelonephritis acute and chronic
Calculus of kidney and ureter
Other disorders of kidney and ureter (cyst, stricture, obstruction, reflux, etc)
Calculus of lower urinary tract
Cystitis
Urethritis, not sexually transmitted and urethral syndrome
Other urethritis
Urethral stricture due to infection
Urinary tract infection, site not specified
Hematuria
Hypertrophy (benign) of prostate without urinary obstruction
Hypertrophy (benign) of prostate with urinary obstruction
Nodular prostate without urinary obstruction
Nodular prostate with urinary obstruction
Benign localized hyperplasia of prostate without urinary obstruction
Benign localized hyperplasia of prostate with urinary obstruction
Hyperplasia of prostate, unspecified, without urinary obstruction
Hyperplasia of prostate, unspecified, with urinary obstruction
Inflammatory diseases of prostate
Other disorders of prostate (calculus, congestion, atrophy, etc)
PeaceHealth Laboratories | Medicare Coverage Policies
117
Urine Culture..
con’t
604.0–604.99
608.0–608.9
614.0–614.9
615.0–615.9
616.0
616.10–616.11
616.2–616.9
619.0–619.9
625.6
639.0
639.5
646.60–646.64
670.00–670.04
670.10
670.12
670.14
670.20
670.22
670.24
670.30
670.32
670.34
670.80
670.82
670.84
672.00–672.04
724.5
771.81-771.83
780.02
780.60-780.66
780.79
780.93
780.94
780.96
780.97
780.99
785.0
785.50–785.59
788.0–788.99
87086, 87088, 87184, 87186
Orchitis and epididymitis
Other disorders of male genital organs (seminal vesiculitis, spermatocele, etc)
Inflammatory disease of ovary, fallopian tube, pelvic cellular tissue, and peritoneum
Inflammatory disease of uterus, except cervix
Cervicitis and endocervicitis
Vaginitis and vulvovaginitis
Other inflammatory conditions of cervix, vagina and vulva
Fistula involving female genital tract
Stress incontinence, female
Genital tract and pelvic infection complicating abortion, ectopic or molar pregnancies
Shock complicating abortion, ectopic or molar pregnancies
Infections of genitourinary tract in pregnancy
Major puerperal infection
Puerperal endometritis, unspecified as to episode of care or not applicable
Puerperal endometritis, delivered, with mention of postpartum complication
Puerperal endometritis, postpartum condition or complication
Puerperal sepsis, unspecified as to episode of care or not applicable
Puerperal sepsis, delivered, with mention of postpartum complication
Puerperal sepsis, postpartum condition or complication
*Puerperal septic thrombophlebitis, unspecified as to episode of care or not
applicable
Puerperal septic thrombophlebitis, delivered, with mention of postpartum
complication
Puerperal septic thrombophlebitis, postpartum condition or complication
Other major puerperal infection, unspecified as to episode of care or not
applicable
Other major puerperal infection, delivered, with mention of postpartum
complication
Other major puerperal infection, postpartum condition or complication
Pyrexia of unknown origin during the puerperium
Backache, unspecified
Other infection specific to the perinatal period
Transient alteration of awareness
Fever/chills
Other malaise and fatigue
Memory loss
Early satiety
Generalized pain
Altered mental status
Other general symptoms
Tachycardia, unspecified
Shock without mention of trauma
Symptoms involving urinary system (renal colic, dysuria, retention of urine,
incontinence of urine, frequency, polyuria, nocturia, oliguria, anuria, other
abnormality of urination, urethral discharge, travasation of urine, other
symptoms of urinary system)
PeaceHealth Laboratories | Medicare Coverage Policies
118
Urine Culture..
con’t
789.00–789.09
789.60–789.7
790.7
791.0–791.9
799.3
939.0
939.3
V44.50–V44.6
V55.5–V55.6
V58.69
87086, 87088, 87184, 87186
Abdominal pain
Abdominal tenderness
Bacteremia
Nonspecific findings on examination of urine (proteinuria, chyluria,
hemoglobinuria, myoglobinuria, biliuria, glycosuria, acetonuria, other cells and
casts in urine, other nonspecific findings on examination of urine)
Debility, unspecified (only for declining functional status)
Foreign body in genitourinary tract, bladder and urethra
Foreign body in genitourinary tract, penis
Artificial cystostomy or other artificial opening of urinary tract status
Attention to cystostomy or other artificial opening of urinary tract
Long-term (current) use of other medications
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Vitamin D Assay Testing
Policy # L32132
Policy Type: LCD (Local Coverage Decision)
CPT CODE(S)
82306
TEST NAME
VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED
82652
VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED
The following ICD-9 CM codes support the medical necessity of CPT code 82306
ICD-9 CODES
ICD-9 DESCRIPTION
252.00
Hyperparathyroidism, unspecified
252.01
Primary hyperparathyroidism
252.02
Secondary hyperparathyroidism, non-renal
252.08
Other hyperparathyroidism
252.1
Hypoparathyroidism
261
Nutritional marasmus
262
Other severe protein-calorie malnutrition
268.0
Rickets active
268.2
Osteomalacia unspecified
268.9*
Unspecified vitamin d deficiency
275.3
Disorders of phosphorus metabolism
275.40*
Unspecified disorder of calcium metabolism
275.41
Hypocalcemia
275.42
Hypercalcemia
278.4
Hypervitaminosis d
571.9
Unspecified chronic liver disease without alcohol
579.0
Celiac disease
579.1
Tropical sprue
579.2
Blind loop syndrome
579.3
Other and unspecified postsurgical nonabsorption
579.4
Pancreatic steatorrhea
579.8
Other specified intestinal malabsorption
579.9
Unspecified intestinal malabsorption
585.3
Chronic kidney disease, stage iii (moderate)
585.4
Chronic kidney disease, stage iv (severe)
585.5
Chronic kidney disease, stage v
585.6
End stage renal disease
588.81
Secondary hyperparathyroidism (of renal origin)
733.00
Osteoporosis unspecified
733.01
Senile osteoporosis
733.02
Idiopathic osteoporosis
733.09
Other osteoporosis
733.90
Disorder of bone and cartilage unspecified
756.52
Osteopetrosis
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Vit D Assay.. con’t
82306, 82652
268.9* If more than one LCD-listed condition contributes to Vit. D deficiency in a given patient and/or is
improved by Vit. D administration, coders should use: ICD-9-CM 268.9 UNSPECIFIED VITAMIN D
DEFICIENCY. This code should not be used for any other indication.
275.40* Use only for HYPERCALCIURIA
The following ICD-9-CM codes support the medical necessity of CPT code 82652
ICD-9 CODES
ICD-9 DESCRIPTION
268.0
Rickets active
268.2*
Osteomalacia unspecified
275.40*
Unspecified disorder of calcium metabolism
275.42*
Hypercalcemia
592.0
Calculus of kidney
592.1
Calculus of ureter
592.9
Urinary calculus unspecified
268.2* Use only for tumor-induced osteomalacia
275.40* Use only for unexplained hypercalciuria
275.42* Use only for unexplained hypercalcemia
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Medicare Coverage Policies
Additional Coding Guidelines
190.12 – Urine Culture, Bacterial
1. Specific coding guidelines:
a. Use CPT 87086 Culture, bacterial, urine; quantitative, colony count where a urine culture colony count
is performed to determine the approximate number of bacteria present per milliliter of urine. The
number of units of service is determined by the number of specimens.
b. Use CPT 87088 where a commercial kit uses manufacturer defined media for isolation, presumptive
identification, and quantitation of morphotypes present. The number of units of service is determined
by the number of specimens.
c. Use CPT 87088 where identification of morphotypes recovered by quantitative culture or commercial
kits and deemed to represent significant bacteriuria requires the use of additional testing, for example,
biochemical test procedures on colonies. Identification based solely on visual observation of the primary
media is usually not adequate to justify use of this code. The number of units of service is determined by
the number of isolates.
d. Use CPT 87184 or 87186 where susceptibility testing of isolates deemed to be significant is performed
concurrently with identification. The number of units of service is determined by the number of isolates.
These codes are not exclusively used for urine cultures but are appropriate for isolates from other
sources as well.
e. Appropriate combinations are as follows: CPT 87086, 1 per specimen with 87088, 1 per isolate and
87184 or 87186 where appropriate.
f. Culture for other specific organism groups not ordinarily recovered by media used for aerobic urine
culture may require use of additional CPT codes (for example, anaerobes from suprapubic samples).
g. Identification of isolates by non-routine, nonbiochemical methods may be coded appropriately (for
example, immunologic identification of streptococci, nucleic acid techniques for identification of N.
gonorrhoeae).
h. While infrequently used, sensitivity studies by methods other than CPT 87184 or 87186 are
appropriate. CPT 87181, agar dilution method, each antibiotic or CPT 87188, macrotube dilution
method, each antibiotic may be used. The number of units of service is the number of antibiotics
multiplied by the number of unique isolates.
2. ICD-9-CM code 780.02, 780.9 or 799.3 should be used only in the situation of an elderly patient,
immunocompromised patient or patient with neurologic disorder who presents without typical
manifestations of a urinary tract infection but who presents with one of the following signs or
symptoms, not otherwise explained by another co-existing condition: increasing debility; declining
functional status; acute mental changes; changes in awareness; or hypothermia.
3. In cases of post renal-transplant urine culture used to detect clinically significant occult infection in
patients on long term immunosuppressive therapy, use code V58.69.
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Medicare Coverage Policies
Additional Coding Guidelines …(con’t)
190.13 – Human Immunodeficiency Virus (HIV) Testing
(Prognosis Including Monitoring)
1. Specific coding guidelines:
a. Temporary code G0100 has been superseded by code 87536 effective January 1, 1998.
b. CPT codes for quantification should not be used simultaneously with other nucleic acid detection
codes for HIV-1 (that is, 87534, 87535) or HIV-2 (that is, 87537, 87538).
2. Codes 647.60-647.64 should only be used for HIV infections complicating pregnancy.
190.14 - Human Immunodeficiency Virus (HIV) Testing (Diagnosis)
1. Specific coding guidelines:
a. CPT 86701 or 86703 is performed initially. CPT 86702 is performed when 86701 is negative and clinical
suspicion of HIV-2 exists.
b. CPT 86689 is performed only on samples repeatedly positive by 86701, 86702, or 86703.
c. CPT 87534 or 87535 is used to detect HIV-1 RNA where indicated. CPT 87537 or 87538 is used to
detect HIV-2 RNA where indicated.
190.16 – Partial Thromboplastin Time (PTT)
1. When patients are being converted from heparin therapy to warfarin therapy, use code V58.61 to
document the medical necessity of the PTT.
2. When coding for Disseminated Intravascular Coagulation (DIC), use 286.6 or code for the signs and
symptoms clinically indicating DIC.
3. If a specific condition is known and is the reason for a pre-operative test, submit the clinical text
description or ICD-9-CM code describing the condition with the order/referral. If a specific condition or
disease is not known, and the pre-operative test is for pre-operative clearance only, assign code V72.84.
4. Assign codes 289.8 – other specified disease of blood and blood-forming organs only when a specific
disease exists and is indexed to 289.8, (for example, myelofibrosis). Do not assign code 289.8 to report a
patient on long term use of anticoagulant therapy (for example, to report a PTT value or re-check need
for medication adjustment.) Assign code V58.61 to referrals for PTT checks or re-checks. (Reference
AHA’s Coding Clinic, March-April, pg 12 – 1987, 2nd quarter pg 8 – 1989)
190.17 – Prothrombin Time (PT)
1. If a specific condition is known and is the reason for a pre-operative test, submit the text description
or ICD-9-CM code describing the condition with the order/referral. If a specific condition or disease is
not known, and the pre-operative test is for pre-operative clearance only, assign code V72.84.
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Medicare Coverage Policies
Additional Coding Guidelines ...(con’t)
2. Assign codes 289.8 – other specified disease of blood and blood-forming organs only when a specific
disease exists and is indexed to 289.8 (for example, myelofibrosis). Do not assign code 289.8 to report a
patient on long term use of anticoagulant therapy (e.g. to report a PT value or re-check need for
medication adjustment.) Assign code V58.61 to referrals for PT checks or re-checks. (Reference AHA’s
Coding Clinic, March-April, pg 12 – 1987, 2nd quarter pg 8 – 1989)
190.19 – Collagen Crosslinks, Any Method
1. When the indication for the test is long-term administration of glucocorticosteroids, use ICD-9-CM
code V58.69.
190.20 – Blood Glucose Testing
1. A diagnostic statement of impaired glucose tolerance must be evaluated in the context of the
documentation in the medical record in order to assign the most accurate ICD-9-CM code. An
abnormally elevated fasting blood glucose level in the absence of the diagnosis of diabetes is classified
to Code 790.6 - other abnormal blood chemistry. If the provider bases the diagnostic statement of
impaired glucose tolerance” on an abnormal glucose tolerance test, the condition is classified to 790.2 -normal glucose tolerance test. Both conditions are considered indications for ordering glycated
hemoglobin or glycated protein testing in the absence of the diagnosis of diabetes mellitus.
2. When a patient is under treatment for a condition for which the tests in this policy are applicable, the
ICD-9-CM code that best describes the condition is most frequently listed as the reason for the test.
3. When laboratory testing is done solely to monitor response to medication, the most accurate ICD-9CM code to describe the reason for the test would be V58.69 -- long term use of medication.
4. Periodic follow-up for encounters for laboratory testing for a patient with a prior history of a disease,
who is no longer under treatment for the condition, would be coded with an appropriate code from the
V67 category -- follow-up examination.
5. According to ICD-9-CM coding conventions, codes that appear in italics in the Alphabetic and/or
Tabular columns of ICD-9-CM are considered manifestation codes that require the underlying condition
to be coded and sequenced ahead of the manifestation. For example, the diagnostic statement,
“thyrotoxic exophthalmos (376.21),” which appears in italics in the tabular listing, requires that the
thyroid disorder (242.0-242.9) is coded and sequenced ahead of thyrotoxic exophthalmos. Therefore, a
diagnostic statement that is listed as a manifestation in ICD-9-CM must be expanded to include the
underlying disease in order to accurately code the condition.
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Medicare Coverage Policies
Additional Coding Guidelines ...(con’t)
190.21 – Glycated Hemoglobin/Glycated Protein
1. A diagnostic statement of impaired glucose tolerance must be evaluated in the context of the
documentation in the medical record in order to assign the most accurate ICD-9-CM code. An
abnormally elevated fasting blood glucose level in the absence of the diagnosis of diabetes is classified
to Code 790.6 - other abnormal blood chemistry. If the provider bases the diagnostic statement of
impaired glucose tolerance” on an abnormal glucose tolerance test, the condition is classified to 790.2 -normal glucose tolerance test. Both conditions are considered indications for ordering glycated
hemoglobin or glycated protein testing in the absence of the diagnosis of diabetes mellitus.
190.22 – Thyroid Testing
1. When a patient is under treatment for a condition for which the tests in this policy are applicable, the
ICD-9-CM code that best describes the condition is most frequently listed as the reason for the test.
2. When laboratory testing is done solely to monitor response to medication, the most accurate ICD-9CM code to describe the reason for the test would be V58.69 - long term use of medication.
3. Periodic follow-up for encounters for laboratory testing for a patient with a prior history of a disease,
who is no longer under treatment for the condition, would be coded with an appropriate code from the
V67 category -- follow-up examination.
4. According to ICD-9-CM coding conventions, codes that appear in italics in the Alphabetic and/or
Tabular columns of ICD-9-CM are considered manifestation codes that require the underlying condition
to be coded and sequenced ahead of the manifestation. For example, the diagnostic statement
“thyrotoxic exophthalmos (376.21),” which appears in italics in the tabular listing, requires that the
thyroid disorder (242.0-242.9) is coded and sequenced ahead of thyrotoxic exophthalmos. Therefore, a
diagnostic statement that is listed as a manifestation in ICD-9-CM must be expanded to include the
underlying disease in order to accurately code the condition.
5. Use code 728.9 to report muscle weakness as the indication for the test. Other diagnoses included
728.9 do not support medical necessity.
6. Use code 194.8 (Malignant neoplasm of other endocrine glands and related structures, other) to
report multiple endocrine neoplasia syndromes (MEN-1 and MEN-2). Other diagnoses included in 194.8
do not support medical necessity.
190.26 – Carcinoembryonic Antigen
1. To show elevated CEA, use ICD-9-CM 790.99 (Other nonspecific findings on examination of blood)
only if a more specific diagnosis has not been made. If a more specific diagnosis has been made, use the
code for that diagnosis.
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Additional Coding Guidelines ...(con’t)
190.31 – Prostate Specific Antigen
1. To show elevated PSA, use ICD-9-CM code 790.93 (Elevated prostate specific antigen). If a more
specific diagnosis code has been made, use the code for that diagnosis.
L33034 – Urinalysis
1. Contractors may specify Bill Types to help providers identify those Bill Types typically used to report
this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.
Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy
should be assumed to apply equally to all claims.
012x Hospital Inpatient (Medicare Part B only)
013x Hospital Outpatient
014x Hospital – Laboratory Services provided to non-patients
022x Skilled Nursing – Inpatient (Medicare Part B only)
023x Skilled Nursing – Outpatient
085x Critical Access Hospital
2. Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically
used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the
policy services reported under other Revenue Codes are equally subject to this coverage determination.
Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and
the policy should be assumed to apply equally to all Revenue Codes.
030X Laboratory – General Classification
031X Laboratory Pathology –General Classification
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