Medicare National and Local Coverage Determination Policy – FLORIDA Policies in this MLCP Reference Guide apply to testing performed at a Quest Diagnostics facility and apply to Medicare National Coverage Determination Policy. This diagnosis code reference guide is provided as an aid to physicians and office staff in determining when an ABN (Advance Beneficiary Notice) is necessary. Diagnosis codes must be applicable to the patient’s symptoms or conditions and must be consistent with documentation in the patient’s medical record. Quest Diagnostics does not recommend any diagnosis codes and will only submit diagnosis information provided to us by the ordering physician or his/her designated staff. The CPT codes provided are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed. Please note this document has been updated with National Medicare changes effective 4/1/2012 • Click here for National MLCP Policies Tool Document contains information on National Medicare Limited Coverage Policies • • • • • • • • • • • • • • • • • • • • • • • Alpha-Fetoprotein Blood Counts Blood Glucose Testing Carcinoembryonic Antigen Collagen Crosslinks - Any Method Digoxin Therapeutic Drug Assay Fecal Occult Blood Gamma Glutamyl Transferase Glycated Hemoglobin - Glycated Protein Hepatitis Panel/Acute Hepatitis Panel Human Chorionic Gonadotropin Human Immunodeficiency Virus (HIV) Testing (Diagnosis) Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) Lipids Testing Partial Thromboplastin Time (PTT) Prostate Specific Antigen Prothrombin Time (PT) Serum Iron Studies Thyroid Testing Tumor Antigen by Immunoassay CA 15-3 CA 27.29 Tumor Antigen by Immunoassay CA 19-9 Tumor Antigen by Immunoassay CA-125 Urine Culture, Bacterial • Click policy below for Local MLCP Policy Tool Document contains the below Medicare Local MLCP Coverage Policies for lab testing performed in Florida Allergy Testing Aluminum B-Type Natriuretic Peptide (BNP) Circulating tumor cell testing Flow Cytometry Hepatitis B Surface Antibody Hepatitis B Surface Antigen Ionized Calcium Magnesium Non-Covered ICD 9 Parathormone, (Parathyroid Hormone) Qualitative Drug Screening Sedimentation Rate Serum Phosphorus Susceptibility Studies Syphilis Total, Calcium Vitamin D:25 Hydroxy, includes Fraction(S) if performed QuestDiagnostics.com Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Last Updated: 12/05/2013 Medicare Local Coverage Determination Policy – Florida Allergy Testing (L31271) 1 OF 2 Data Source: http://www.cms.gov CPT Code 86003 LCD Description: Allergy is a form of exaggerated sensitivity or hypersensitivity to a substance that is either inhaled, ingested, injected, or comes in contact with the skin or eye. The term allergy is used to describe situations where hypersensitivity results from heightened or altered reactivity of the immune system in response to external substances. Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions as well as localized reactions in any part of the body. The reactions may be acute, sub-acute, or chronic, immediate or delayed, and may be caused by a variety of offending agents; pollen, molds, mites, dust, feathers, animal fur or dander, venoms, foods, drugs, etc. Allergy testing is performed to determine a patient's immunologic sensitivity or reaction to particular allergens for the purpose of identifying the cause of the allergic state, and is based on findings during a complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient. ICD-9-CM Codes that Support Medical Necessity: The Allergy Testing test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference. 372.05 372.14 477.0 477.1 477.2 477.8 477.9 493.00 493.01 493.02 493.90 493.91 493.92 691.8 692.9 693.0 ACUTE ATOPIC CONJUNCTIVITIS OTHER CHRONIC ALLERGIC CONJUNCTIVITIS ALLERGIC RHINITIS DUE TO POLLEN ALLERGIC RHINITIS DUE TO FOOD ALLERGIC RHINITIS, DUE TO ANIMAL (CAT) (DOG) HAIR AND DANDER ALLERGIC RHINITIS DUE TO OTHER ALLERGEN ALLERGIC RHINITIS CAUSE UNSPECIFIED EXTRINSIC ASTHMA UNSPECIFIED EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION ASTHMA UNSPECIFIED ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION OTHER ATOPIC DERMATITIS AND RELATED CONDITIONS CONTACT DERMATITIS AND OTHER ECZEMA, UNSPECIFIED CAUSE DERMATITIS DUE TO DRUGS AND MEDICINES TAKEN INTERNALLY 693.1 693.8 693.9 708.0 708.3 708.8 708.9 782.1 989.5 989.82 995.0 995.1 995.20 995.22 DERMATITIS DUE TO FOOD TAKEN INTERNALLY DERMATITIS DUE TO OTHER SPECIFIED SUBSTANCES TAKEN INTERNALLY DERMATITIS DUE TO UNSPECIFIED SUBSTANCES TAKEN INTERNALLY ALLERGIC URTICARIA DEMATOLOGRAPHIC URTICARIA OTHER SPECIFIED URTICARIA UNSPECIFIED URTICARIA RASH OR OTHER NONSPECIFIED SKIN ERUPTION TOXIC EFFECT ON VENOM TOXIC EFFECT OF LATEX OTHER ANAPHYLACTIC REACTION ANGIONEUROTIC EDEMA NOT ELSEWHERE CLASSIFIED UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG MEDICINAL AND BIOLOGICAL SUBSTANCE UNSPECIFIED ADVERSE EFFECT OF ANESTHESIA * ICD-9-CM code V15.09 should be used as a secondary code only and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Allergy Testing (L31271) 2 OF 2 Data Source: http://www.cms.gov CPT Code 86003 LCD Description: Allergy is a form of exaggerated sensitivity or hypersensitivity to a substance that is either inhaled, ingested, injected, or comes in contact with the skin or eye. The term allergy is used to describe situations where hypersensitivity results from heightened or altered reactivity of the immune system in response to external substances. Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions as well as localized reactions in any part of the body. The reactions may be acute, sub-acute, or chronic, immediate or delayed, and may be caused by a variety of offending agents; pollen, molds, mites, dust, feathers, animal fur or dander, venoms, foods, drugs, etc. Allergy testing is performed to determine a patient's immunologic sensitivity or reaction to particular allergens for the purpose of identifying the cause of the allergic state, and is based on findings during a complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient. ICD-9-CM Codes that Support Medical Necessity: The Allergy Testing test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference. 995.27 995.29 995.3 995.60 – 995.68 V15.09* OTHER DRUG ALLERGY UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE ALLERY UNSPECIFIED NOT ELSEWHERE CLASSIFIED ANAPHYLACTIC REACTION PERSONAL HISTORY OF OTHER ALLERGY OTHER THAN TO MEDICINAL AGENTS * ICD-9-CM code V15.09 should be used as a secondary code only and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Florida Aluminum (L29058) Data Source: http://www.cms.gov CPT Code 82108 LCD Description: Aluminum is the third most prevalent element in the earth’s crust. The gastrointestinal tract is virtually impervious to aluminum, absorption being around 2%. Factors regulating aluminum’s crossing of the blood-brain barrier are not well understood. Serum aluminum correlates with encephalopathy. Aluminum toxicity has been recognized in many settings where exposure is heavy or prolonged and/or where renal function is limited. ICD-9-CM Codes that Support Medical Necessity: The Aluminum test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference. 268.2 275.49 280.9 284.81 – 284.89 284.9 285.1 294.8 348.30 – 348.39 359.4* 428.1 429.3 585.1 – 585.9 733.10 – 733.19 965.1 972.2 973.0 976.1 OSTEOMALACIA UNSPECIFIED OTHER DISORDERS OR CALCIUM METABOLISM IRON DEFICIENCY ANEMIA UNSPECIFIED RED CELL APLASIA(ACQUIRED) (ADULT) (WITH THYMOMA) – OTHER SPECIFIED APLASTIC ANEMIAS APLASTIC ANEMIA UNSPECIFIED ACUTE POSTHEMORRHAGIC ANEMIA OTHER PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE ENCEPHAOPATHY UNSPECIFIED – OTHER TOXIC MYOPATHY LEFT HEART FAILURE CARDIOMEGALY CHRONIC KIDNEY DISEASE, STAGE 1 – CHRONIC KIDNEY DISEASE UNSPECIFIED PATHOLOGICAL FRACTURE UNSPECIFIED/OTHER SITE POISONING BY SALICYLATES POISONING BY ANTILIPEMIC AND ANTIARTERIOSCLEROTIC DRUGS POISONING BY ANTACIDS AND ANTIGASTRIC SECRETION DRUGS POISIONING BY ANTIPRURITICS 976.2 POISONING BY LOCAL ASTRINGENTS AND LOCAL DETERGENTS 976.3 POISONING BY EMOLLIENTS DEMULCENTS AND PROTECTANTS 985.9 TOXIC EFFECT OR UNSPECIFIED METAL E858.3* ACCIDENTAL POISONING BY AGENTS PRIMARILY AFFECTING CARDIOVASCULAR SYSTEM E858.4* ACCIDENTAL POISONING BY AGENTS PRIMARILY AFFECTING GASTOINTESTINAL SYSTEM E858.7* ACCIDENTAL POISONING BY AGENTS PRIMARILY AFFECTING SKIN AND MUCOUS MEMBRANE OPTHALMOLOGICAL OTORHINOLARYNGOLOGICAL AND DENTAL DRUGS E935.3* SALICYLATES CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE E942.2* ANTILIPEMIC AND ANTIARTERIOSCLEROTIC DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE E943.0* ANTACIDS AND ANTIGASTRIC SECRETION DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE E946.2* - E946.3* ASTRINGENTS/EMOLLIENTS CAUSING ADVERSE EFFECTS E950.0* SUICIDE AND SELF-INFLICTED POISONING E950.4* SUICIDE AND SELF-INFLICTED POISONING - OTHER * These ICD-9-CM codes require dual diagnosis. ICD-9-CM code 359.4 must be accompanied by the appropriate E diagnosis code to identify the toxic agent. Conversely, the E diagnosis codes must be billed with ICD-9-CM code 359.4 to identify the indication of toxic myopathy. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida B-Type Natriuretic Peptide (BNP) (L29065) Data Source: http://www.cms.gov CPT Code 83880 LCD Description:. LCD Description:. Congestive Heart Failure (CHF) is characterized by a progressive activation of the neurohormonal systems that control vasoconstriction and sodium retention; the activation of these systems plays a role in its pathogenesis and progression. As the heart fails, B-Type Natriuretic Peptide (BNP), a cardiac neurohormone is secreted from the cardiac ventricles in response to ventricular volume expansion and pressure overload. Used in conjunction with other clinical information, rapid measurement of BNP is useful in establishing or excluding the diagnosis and assessment of severity of CHF in patients with acute dyspnea so that appropriate and timely treatment can be initiated. This test is also used to predict the long-term risk of cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after an acute coronary event. For the purposes of this policy, the total and N terminal assays are both acceptable. ICD-9-CM Codes that Support Medical Necessity: The B-Type Natriuretic Peptide (BNP is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided 402.01 402.11 402.91 404.01 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 404.03 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 404.11 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 404.13 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 404.91 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 404.93 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 410.00 - 410.92 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE 411.1 INTERMEDIATE CORONARY SYNDROME 428.0 CONGESTIVE HEART FAILURE UNSPECIFIED 428.1 LEFT HEART FAILURE 428.20 UNSPECIFIED SYSTOLIC HEART FAILURE 428.21 ACUTE SYSTOLIC HEART FAILURE 428.22 CHRONIC SYSTOLIC HEART FAILURE 428.23 428.30 428.31 428.32 428.33 428.40 428.41 428.42 428.43 428.9 786.00 786.02 786.05 786.06 786.07 786.09 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 RESPIRATORY ABNORMALITY UNSPECIFIED ORTHOPNEA SHORTNESS OF BREATH TACHYPNEA WHEEZING RESPIRATORY ABNORMALITY OTHER This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Circulating tumor cell testing (L32098) Data Source: http://www.cms.gov CPT Codes 86152 and 86153 LCD Description: Circulating tumor cells (CTCs) are rare malignant cells found in the peripheral blood which originate from the primary tumor or metastatic sites. The Detection of CTCs has several propased application, some of which have been reported in well-designed observational studies (prospective and retrospective) of patients with metastatic cancers. There are also several controlled clinical trials in progress assessing the clinical utility of CTC results in the care of patients with metastatic cancers (appliction in clinical decision making that impacts patient outcomes). There are several methods of detecting CTCs whick are in various stages of reseaarch and development. The low level of concentration of malignant epithelial cells in blood samples makes them diffcult to detect though the push to improve surveilance and treatment of cancer patients makes CTC an area of research development. The techniques that have been used to detect CTCs include direct methods (enrichment/detection) including Immunomagnetic Bead Separation, Immunohistochemistry (IHC), automated fluorescent methods. Dielectrophoresis and indirect methods (reversetranscriptase polymerase chain reaction (RT-PCR) nucleic acid analysis). ICD-9-CM Codes that Support Medical Necessity: The Circulating tumor cell testing is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided 153.0 - 153.9 154.0 - 154.8 174.0 - 174.9 175.0 - 175.9 185 196.0 198.3 198.5 MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION - MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS MALIGNANT NEOPLASM OF NIPPLE AND AREOLA 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 PROSTATE SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Flow Cytometry (L31247) 1 of 4 Data Source: http://www.cms.gov CPT Codes 88182, 88184, 88185, 88187, 88188 and 88189 LCD Description: Flow cytometry (FCM) is a procedure which simultaneously measures and analyzes multiple physical characteristics of single cells, as they flow in a fluid stream through a beam of light. The light activates fluorescent molecules, resulting in light scatter, which forms a pattern that can be analyzed for cell characteristics. FCM can be used to analyze blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid organs. Information from the analyzed cells may help determine prognosis, aid in the analysis of effusions, urine, or other fluids in which cancer cells may be few or mixed with benign cells, detect metastases in lymph nodes or bone marrow, or to supplement fine needle aspiration. The flow cytometer is made up of three main systems: fluidics, optics and electronics. The fluidic system transports particles in a stream to the laser beam. The optics system consists of lasers to illuminate the particles in the sample stream and optical filters to direct the resulting light signals to the appropriate detectors. The electronics system converts the detected light signals into electronic signals that can be processed by the computer. Some flow cytometers have a sorting feature which allows the electronic system to initiate sorting decisions to charge and deflect particles. ICD-9-CM Codes that Support Medical Necessity: The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference. CPT 88182 151.0 - 151.9 153.0 - 153.9 154.1 164.2 164.3 174.0 - 174.9 175.0 - 175.9 182.0 183.0 183.8 185 188.0 - 188.8 189.0 189.1 191.0 - 191.9 630 MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE MALIGNANT NEOPLASM OF RECTUM MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM MALIGNANT NEOPLASM OF NIPPLE AND AREOLA 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 CORPUS UTERI EXCEPT ISTHMUS MALIGNANT NEOPLASM OF OVARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA MALIGNANT NEOPLASM OF PROSTATE MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER - MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS MALIGNANT NEOPLASM OF RENAL PELVIS MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE HYDATIDIFORM MOLE USE FOR BILLING CPT CODES 88184, 88185, 88187, 88188, AND 88189 042 079.51 079.52 079.53 099.3 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE I [HTLV-I] HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE II [HTLV-II] HUMAN IMMUNODEFICIENCY VIRUS TYPE 2 [HIV-2] REITER'S DISEASE * According to the IC9-9-CM book, diagnosis codes V42.0 – V42.9 and 289.83 are secondary codes and should not be billed as a primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Flow Cytometry (L31247) 2 of 4 Data Source: http://www.cms.gov CPT Codes 88182, 88184, 88185, 88187, 88188 and 88189 LCD Description: Flow cytometry (FCM) is a procedure which simultaneously measures and analyzes multiple physical characteristics of single cells, as they flow in a fluid stream through a beam of light. The light activates fluorescent molecules, resulting in light scatter, which forms a pattern that can be analyzed for cell characteristics. FCM can be used to analyze blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid organs. Information from the analyzed cells may help determine prognosis, aid in the analysis of effusions, urine, or other fluids in which cancer cells may be few or mixed with benign cells, detect metastases in lymph nodes or bone marrow, or to supplement fine needle aspiration. The flow cytometer is made up of three main systems: fluidics, optics and electronics. The fluidic system transports particles in a stream to the laser beam. The optics system consists of lasers to illuminate the particles in the sample stream and optical filters to direct the resulting light signals to the appropriate detectors. The electronics system converts the detected light signals into electronic signals that can be processed by the computer. Some flow cytometers have a sorting feature which allows the electronic system to initiate sorting decisions to charge and deflect particles. ICD-9-CM Codes that Support Medical Necessity: The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference. 150.0 - 150.9 MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE 151.0 - 151.9 MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE 153.0 - 153.9 MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE 154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION 154.1 MALIGNANT NEOPLASM OF RECTUM 174.0 - 174.9 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE 175.0 - 175.9 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST - MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST 183.0 MALIGNANT NEOPLASM OF OVARY 183.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA 185 MALIGNANT NEOPLASM OF PROSTATE 188.0 - 188.9 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED 193 MALIGNANT NEOPLASM OF THYROID GLAND 194.0 197.2 197.6 200.00 - 208.92 227.0 233.0 238.71 - 238.79 259.2 273.1 273.2 273.3 273.8 273.9 279.00 - 279.9 282.0 282.1 285.9 MALIGNANT NEOPLASM OF ADRENAL GLAND SECONDARY MALIGNANT NEOPLASM OF PLEURA SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM RETICULOSARCOMA UNSPECIFIED SITE UNSPECIFIED LEUKEMIA, IN RELAPSE BENIGN NEOPLASM OF ADRENAL GLAND CARCINOMA IN SITU OF BREAST ESSENTIAL THROMBOCYTHEMIA – OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES CARCINOID SYNDROME MONOCLONAL PARAPROTEINEMIA OTHER PARAPROTEINEMIAS MACROGLOBULINEMIA OTHER DISORDERS OF PLASMA PROTEIN METABOLISM UNSPECIFIED DISORDER OF PLASMA PROTEIN METABOLISM HYPOGAMMAGLOBULINEMIA UNSPECIFIED - UNSPECIFIED DISORDER OF IMMUNE MECHANISM HEREDITARY SPHEROCYTOSIS HEREDITARY ELLIPTOCYTOSIS ANEMIA UNSPECIFIED * According to the IC9-9-CM book, diagnosis codes V42.0 – V42.9 and 289.83 are secondary codes and should not be billed as a primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Flow Cytometry (L31247) 3 of 4 Data Source: http://www.cms.gov CPT Codes 88182, 88184, 88185, 88187, 88188 and 88189 LCD Description: Flow cytometry (FCM) is a procedure which simultaneously measures and analyzes multiple physical characteristics of single cells, as they flow in a fluid stream through a beam of light. The light activates fluorescent molecules, resulting in light scatter, which forms a pattern that can be analyzed for cell characteristics. FCM can be used to analyze blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid organs. Information from the analyzed cells may help determine prognosis, aid in the analysis of effusions, urine, or other fluids in which cancer cells may be few or mixed with benign cells, detect metastases in lymph nodes or bone marrow, or to supplement fine needle aspiration. The flow cytometer is made up of three main systems: fluidics, optics and electronics. The fluidic system transports particles in a stream to the laser beam. The optics system consists of lasers to illuminate the particles in the sample stream and optical filters to direct the resulting light signals to the appropriate detectors. The electronics system converts the detected light signals into electronic signals that can be processed by the computer. Some flow cytometers have a sorting feature which allows the electronic system to initiate sorting decisions to charge and deflect particles. ICD-9-CM Codes that Support Medical Necessity: The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference. 287.1 287.30 – 287.39 287.5 288.00 – 288.09 288.1 288.2 288.3 288.4 288.50 – 288.59 288.60 288.61 288.62 288.64 288.65 288.69 288.8 288.9 289.4 289.50 – 289.59 289.83* QUALITATIVE PLATELET DEFECTS PRIMARY THROMOCYTOPENIA, UNSPECIFIED – OTHER THROMBOCYTOPENIA UNSPECIFIED NEUTROPENIA, UNSPECIFIED – OTHER FUNCTIONAL DISORDERS OF POLYMORPHONUCLEAR NEUTROPHILS GENETIC ANOMALIES OF LEUKOCYTES EOSINOPHILIA HEMOPHAGOCYTIC SYNDROMES LEUKOCYTOPENIA, UNSPECIFIED – OTHER DECREASE WHITE BLOOD CELL COUNT LEUKOCYTOSIS, UNSPECIFIED LYMPHOCYTOSIS (SYMPTOMATIC) LEUKMOID REACTION PLASMACYTOSIS BASOPHILIA OTHER ELEVATED WHITE BLOOD CELL COUNT OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS UNSPECIFIED DISEASE OF WHITE BLOOD CELLS HYPERSPLENISM DISEASE OF SPLEEN UNSPECIFIED, OTHER MYELOFIBROSIS 289.9 364.3 452 453.9 555.0 – 555.9 556.0 556.1 556.2 556.3 556.4 556.5 556.6 556.9 630.. 696.0 714.30 720.0 – 720.9 UNSPECIFIED DISEASES OF BLOOD AND BLOOD-FORMING ORGANS UNSPECIFIED IRIDOCYCLITIS PORTAL VEIN THROMBOSIS EMBOLISM AND THROMBOSIS OF UNSPECIFIED SITE REGIONAL ENTERITIS OF SMALL INTESTINE – REGIONAL ENTERITIS OF UNSPECIFIED SITE ULCERATIVE (CHRONIC) ENTEROCOLITIS ULCERATIVE (CHRONIC) ILEOCOLOYIS ULCERATIVE (CHRONIC) PROCTITIS ULCERATIVE (CHRONIC) PROCTOSIGMOIDITIS PSEUDOPOLYPOSIS OF COLON LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS UNIVERSAL ULCERATIVE (CHRONIC) COLITIS ULCERATIVE COLITIS UNSPECIFIED HYDATIDIFORM MOLE PSORIATIC ARTHROPATHY CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS ANKYLOSING SPONDYLITIS – UNSPECIFIED INFLAMMATORY SPONDYLOPATHY * According to the IC9-9-CM book, diagnosis codes V42.0 – V42.9 and 289.83 are secondary codes and should not be billed as a primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Flow Cytometry (L31247) 4 of 4 Data Source: http://www.cms.gov CPT Codes 88182, 88184, 88185, 88187, 88188 and 88189 LCD Description: Flow cytometry (FCM) is a procedure which simultaneously measures and analyzes multiple physical characteristics of single cells, as they flow in a fluid stream through a beam of light. The light activates fluorescent molecules, resulting in light scatter, which forms a pattern that can be analyzed for cell characteristics. FCM can be used to analyze blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid organs. Information from the analyzed cells may help determine prognosis, aid in the analysis of effusions, urine, or other fluids in which cancer cells may be few or mixed with benign cells, detect metastases in lymph nodes or bone marrow, or to supplement fine needle aspiration. The flow cytometer is made up of three main systems: fluidics, optics and electronics. The fluidic system transports particles in a stream to the laser beam. The optics system consists of lasers to illuminate the particles in the sample stream and optical filters to direct the resulting light signals to the appropriate detectors. The electronics system converts the detected light signals into electronic signals that can be processed by the computer. Some flow cytometers have a sorting feature which allows the electronic system to initiate sorting decisions to charge and deflect particles. ICD-9-CM Codes that Support Medical Necessity: The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference. 785.6 789.2 789.30 – 789.39 791.0 795.4 996.80 – 996.89 V08 V10.60 – V10.69 V42.0 – V42.9 ENLARGEMENT OF LYMPH NODES SPLENOMEGALY ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED/OTHER SITE PROTEINURIA OTHER NONSPECIFIED ABNORMAL HISTOLOGICAL FINDINGS COMPLICATIONS OF UNSPECIFIED/OTHER TRANSPLANTED ORGAN ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION PERSONAL HISTORY OF UNSECIFIED/OTHER LEUKEMIA KIDNEY REPLACED BY TRANSPLANT – UNSPECIFIED ORGAN OR TISSUE REPLACED BY TRANSPLANT * According to the IC9-9-CM book, diagnosis codes V42.0 – V42.9 and 289.83 are secondary codes and should not be billed as a primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Hepatitis B Surface Antibody (L29189) 1 of 2 Data Source: http://www.cms.gov CPT Code 86706 LCD Description:. Hepatitis refers to inflammation of the liver. Approximately 50% of all acute viral hepatitis cases in the United States are type B. Hepatitis B is caused by the hepatitis B virus (HBV) which is spread by blood and serum-derived fluids through direct contact with these body fluids (such as transmission through parenteral, sexual and perinatal modes). The incubation period for hepatitis B can be six weeks to six months with a slow onset. The most frequent presenting symptoms of acute viral hepatitis are low-grade fever, anorexia, fatigue, myalgia, and nausea followed one to two weeks later by jaundice. Dark urine and clay colored stools present several days before jaundice. After the onset of jaundice, the liver enlarges and becomes tender. About 5% of patients infected with the hepatitis B virus develop what is coined the “serum-sickness syndrome”. The syndrome includes the symptoms of jaundice, fever, rash and arthralgia. Hepatitis B may be quite mild, while a few patients could rapidly progress to death suffering from acute necrosis of the liver. Some patients with hepatitis B (approximately 6%-10%) may progress to a persistent carrier status confirmed by the consistently present hepatitis B surface antigen in their blood. These patients are highly likely to transmit hepatitis B. Each case of hepatitis B is treated symptomatically. Hepatitis B surface antibody (HbsAb or anti-HBs) is present in the serum of patients who have resolved a previous hepatitis B infection or have been vaccinated against hepatitis B. The disappearance of hepatitis B antigen with the appearance of hepatitis B antibody signals recovery from the hepatitis B infection, the status of noninfectivity and protection from recurrent hepatitis B infection. Hepatitis B surface antibody can be detected several weeks to several years after Hepatitis B antigen can no longer be detected. It may persist for life after the acute infection has been resolved. Since there are different serologic subtypes of the hepatitis B virus, it is possible for a patient to have an antibody for one subtype and be infected with another. Transfused individuals or hemophiliacs receiving plasma components may have false positive tests. Individuals vaccinated with HBV vaccine will have antibodies. The appearance of the hepatitis B antibody following vaccination signals successful vaccination against hepatitis B. The detection of hepatitis B surface antibody in the patient’s serum can be performed by either the radioimmunoassay (RIA) or enzyme immunoassay (EIA) method. The reference range varies with the clinical circumstance. ICD-9-CM Codes that Support Medical Necessity The Hepatitis B Surface Antibody is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must Vaccination and Serologic Studies support the medical necessity for the test(s) provided. 070.20 - 070.23 070.30 - 070.33 403.01 403.11 404.02 404.03 VIRAL HEPATITIS B WITH HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA – CHRONIC VIRAL HEPATITIS B WITH HEPATIC COMA WITH HEPATITIS DELTA VIRAL HEPATITIS B WITHOUT HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA – CHRONIC VIRAL HEPATITIS B WITHOUT HEPATIC COMA WITH HEPATITIS DELTA 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 V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE Freq. of Status HBsAb Surveillance Unvaccinated Susceptible - Semiannually HBsAg Carrier - None HBsAb positive (*) - Annually Vaccinated HBsAb positive (*) - Annually HBsAb of 9 or less SRUs by RIA – Semiannually Note: Billing for Hepatitis B Surface Antibody for ESRD beneficiaries requires dual diagnoses. Please submit codes 403.01, 403.11, 404.02, 404.03, 404.12, 404.13, or 585.4-585.6 and *V45.11 to report the approved indication. * According to the ICD-9-CM book, Diagnosis code V45.11 is a secondary diagnosis code and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Hepatitis B Surface Antibody (L29189) 2 of 2 Data Source: http://www.cms.gov CPT Code 86706 LCD Description:. Hepatitis refers to inflammation of the liver. Approximately 50% of all acute viral hepatitis cases in the United States are type B. Hepatitis B is caused by the hepatitis B virus (HBV) which is spread by blood and serum-derived fluids through direct contact with these body fluids (such as transmission through parenteral, sexual and perinatal modes). The incubation period for hepatitis B can be six weeks to six months with a slow onset. The most frequent presenting symptoms of acute viral hepatitis are low-grade fever, anorexia, fatigue, myalgia, and nausea followed one to two weeks later by jaundice. Dark urine and clay colored stools present several days before jaundice. After the onset of jaundice, the liver enlarges and becomes tender. About 5% of patients infected with the hepatitis B virus develop what is coined the “serum-sickness syndrome”. The syndrome includes the symptoms of jaundice, fever, rash and arthralgia. Hepatitis B may be quite mild, while a few patients could rapidly progress to death suffering from acute necrosis of the liver. Some patients with hepatitis B (approximately 6%-10%) may progress to a persistent carrier status confirmed by the consistently present hepatitis B surface antigen in their blood. These patients are highly likely to transmit hepatitis B. Each case of hepatitis B is treated symptomatically. Hepatitis B surface antibody (HbsAb or anti-HBs) is present in the serum of patients who have resolved a previous hepatitis B infection or have been vaccinated against hepatitis B. The disappearance of hepatitis B antigen with the appearance of hepatitis B antibody signals recovery from the hepatitis B infection, the status of noninfectivity and protection from recurrent hepatitis B infection. Hepatitis B surface antibody can be detected several weeks to several years after Hepatitis B antigen can no longer be detected. It may persist for life after the acute infection has been resolved. Since there are different serologic subtypes of the hepatitis B virus, it is possible for a patient to have an antibody for one subtype and be infected with another. Transfused individuals or hemophiliacs receiving plasma components may have false positive tests. Individuals vaccinated with HBV vaccine will have antibodies. The appearance of the hepatitis B antibody following vaccination signals successful vaccination against hepatitis B. The detection of hepatitis B surface antibody in the patient’s serum can be performed by either the radioimmunoassay (RIA) or enzyme immunoassay (EIA) method. The reference range varies with the clinical circumstance. ICD-9-CM Codes that Support Medical Necessity The Hepatitis B Surface Antibody is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must Vaccination and Serologic Studies support the medical necessity for the test(s) provided. 404.12 404.13 585.4 585.5 585.6 V01.71 - V01.79 V05.3 V45.11* V67.59 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT 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 CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE CONTACT OR EXPOSURE TO VARICELLA - CONTACT OR EXPOSURE TO OTHER VIRAL DISEASES NEED FOR PROPHYLACTIC VACCINATION AND INOCULATION AGAINST VIRALHEPATITIS RENAL DIALYSIS STATUS OTHER FOLLOW-UP EXAMINATION Freq. of Status HBsAb Surveillance Unvaccinated Susceptible - Semiannually HBsAg Carrier - None HBsAb positive (*) - Annually Vaccinated HBsAb positive (*) - Annually HBsAb of 9 or less SRUs by RIA – Semiannually Note: Billing for Hepatitis B Surface Antibody for ESRD beneficiaries requires dual diagnoses. Please submit codes 403.01, 403.11, 404.02, 404.03, 404.12, 404.13, or 585.4-585.6 and *V45.11 to report the approved indication. * According to the ICD-9-CM book, Diagnosis code V45.11 is a secondary diagnosis code and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Hepatitis B Surface Antigen (L29189) 1 of 3 Data Source: http://www.cms.gov CPT Code 87340 LCD Description:. Hepatitis refers to inflammation of the liver. Approximately 50% of all acute viral hepatitis cases in the United States are type B. Hepatitis B is caused by the hepatitis B virus (HBV) which is spread by blood and serum-derived fluids through direct contact with these body fluids (such as transmission through parenteral, sexual and perinatal modes). The incubation period for hepatitis B can be six weeks to six months with a slow onset. The most frequent presenting symptoms of acute viral hepatitis are low-grade fever, anorexia, fatigue, myalgia, and nausea followed one to two weeks later by jaundice. Dark urine and clay colored stools present several days before jaundice. After the onset of jaundice, the liver enlarges and becomes tender. About 5% of patients infected with the hepatitis B virus develop what is coined the “serum-sickness syndrome”. The syndrome includes the symptoms of jaundice, fever, rash and arthralgia. Hepatitis B may be quite mild, while a few patients could rapidly progress to death suffering from acute necrosis of the liver. Some patients with hepatitis B (approximately 6%-10%) may progress to a persistent carrier status confirmed by the consistently present hepatitis B surface antigen in their blood. These patients are highly likely to transmit hepatitis B. Each case of hepatitis B is treated symptomatically. Hepatitis B surface antigen (HBsAg) is the earliest indicator of an acute hepatitis B infection. It can be detected one to seven weeks before liver enzyme elevation or the onset of clinical symptoms. The serology of 50% of affected patients will be positive three weeks after acute onset, while at the seventeen week mark only 10% will remain positive. There is evidence of a “window” stage where the hepatitis B surface antigen has become negative and the patient has not yet developed the hepatitis B surface antibody. The chronic carrier state is indicated by the persistence of hepatitis B surface antigen over six months and longer (even years) while never seroconverting to hepatitis B surface antibody. The reference range is negative. The detection of the hepatitis B surface antigen establishes the presence of infection and implies infectivity. ICD-9-CM Codes that Support Medical Necessity The Hepatitis B surface antigen (HBsAg) is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 070.20 - 070.23 070.30 - 070.33 070.6 070.9 403.01 403.11 404.02 404.03 404.12 404.13 VIRAL HEPATITIS B WITH HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA - CHRONIC VIRAL HEPATITIS B WITH HEPATIC COMA WITH HEPATITIS DELTA VIRAL HEPATITIS B WITHOUT HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA – CHRONIC VIRAL HEPATITIS B WITHOUT HEPATIC COMA WITH HEPATITIS DELTA UNSPECIFIED VIRAL HEPATITIS WITH HEPATIC COMA UNSPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA 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 V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 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, WITHOUT 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 CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE Note: Billing for Hepatitis B Surface Antigen for ESRD beneficiaries requires dual diagnoses. Please submit codes 403.01, 403.11, 404.02, 404.03, 404.12, 404.13, or 585.4-585.6 and *V45.1 to report the approved indication. * According to the ICD-9-CM book, Diagnosis code V45.1 is a secondary diagnosis code and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Hepatitis B Surface Antigen (L29189) 2 of 3 Data Source: http://www.cms.gov CPT Code 87340 LCD Description:. Hepatitis refers to inflammation of the liver. Approximately 50% of all acute viral hepatitis cases in the United States are type B. Hepatitis B is caused by the hepatitis B virus (HBV) which is spread by blood and serum-derived fluids through direct contact with these body fluids (such as transmission through parenteral, sexual and perinatal modes). The incubation period for hepatitis B can be six weeks to six months with a slow onset. The most frequent presenting symptoms of acute viral hepatitis are low-grade fever, anorexia, fatigue, myalgia, and nausea followed one to two weeks later by jaundice. Dark urine and clay colored stools present several days before jaundice. After the onset of jaundice, the liver enlarges and becomes tender. About 5% of patients infected with the hepatitis B virus develop what is coined the “serum-sickness syndrome”. The syndrome includes the symptoms of jaundice, fever, rash and arthralgia. Hepatitis B may be quite mild, while a few patients could rapidly progress to death suffering from acute necrosis of the liver. Some patients with hepatitis B (approximately 6%-10%) may progress to a persistent carrier status confirmed by the consistently present hepatitis B surface antigen in their blood. These patients are highly likely to transmit hepatitis B. Each case of hepatitis B is treated symptomatically. Hepatitis B surface antigen (HBsAg) is the earliest indicator of an acute hepatitis B infection. It can be detected one to seven weeks before liver enzyme elevation or the onset of clinical symptoms. The serology of 50% of affected patients will be positive three weeks after acute onset, while at the seventeen week mark only 10% will remain positive. There is evidence of a “window” stage where the hepatitis B surface antigen has become negative and the patient has not yet developed the hepatitis B surface antibody. The chronic carrier state is indicated by the persistence of hepatitis B surface antigen over six months and longer (even years) while never seroconverting to hepatitis B surface antibody. The reference range is negative. The detection of the hepatitis B surface antigen establishes the presence of infection and implies infectivity. ICD-9-CM Codes that Support Medical Necessity The Hepatitis B surface antigen (HBsAg) is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 446.0 570 573.1 573.2 573.3 585.4 585.5 585.6 719.40 - 719.49 729.1 774.4 780.60 780.61 780.63 780.66 780.79 782.1 782.4 POLYARTERITIS NODOSA ACUTE AND SUBACUTE NECROSIS OF LIVER HEPATITIS IN VIRAL DISEASES CLASSIFIED ELSEWHERE HEPATITIS IN OTHER INFECTIOUS DISEASES CLASSIFIED ELSEWHERE HEPATITIS UNSPECIFIED CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE PAIN IN JOINT SITE UNSPECIFIED - PAIN IN JOINT INVOLVING MULTIPLE SITES MYALGIA AND MYOSITIS UNSPECIFIED PERINATAL JAUNDICE DUE TO HEPATOCELLULAR DAMAGE FEVER, UNSPECIFIED FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE POSTVACCINATION FEVER FEBRILE NONHEMOLYTIC TRANSFUSION REACTION OTHER MALAISE AND FATIGUE RASH AND OTHER NONSPECIFIC SKIN ERUPTION JAUNDICE UNSPECIFIED NOT OF NEWBORN Note: Billing for Hepatitis B Surface Antigen for ESRD beneficiaries requires dual diagnoses. Please submit codes 403.01, 403.11, 404.02, 404.03, 404.12, 404.13, or 585.4-585.6 and *V45.1 to report the approved indication. * According to the ICD-9CM book, Diagnosis code V45.1 is a secondary diagnosis code and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Hepatitis B Surface Antigen (L29189) 3 of 3 Data Source: http://www.cms.gov CPT Code 87340 LCD Description:. Hepatitis refers to inflammation of the liver. Approximately 50% of all acute viral hepatitis cases in the United States are type B. Hepatitis B is caused by the hepatitis B virus (HBV) which is spread by blood and serum-derived fluids through direct contact with these body fluids (such as transmission through parenteral, sexual and perinatal modes). The incubation period for hepatitis B can be six weeks to six months with a slow onset. The most frequent presenting symptoms of acute viral hepatitis are low-grade fever, anorexia, fatigue, myalgia, and nausea followed one to two weeks later by jaundice. Dark urine and clay colored stools present several days before jaundice. After the onset of jaundice, the liver enlarges and becomes tender. About 5% of patients infected with the hepatitis B virus develop what is coined the “serum-sickness syndrome”. The syndrome includes the symptoms of jaundice, fever, rash and arthralgia. Hepatitis B may be quite mild, while a few patients could rapidly progress to death suffering from acute necrosis of the liver. Some patients with hepatitis B (approximately 6%-10%) may progress to a persistent carrier status confirmed by the consistently present hepatitis B surface antigen in their blood. These patients are highly likely to transmit hepatitis B. Each case of hepatitis B is treated symptomatically. Hepatitis B surface antigen (HBsAg) is the earliest indicator of an acute hepatitis B infection. It can be detected one to seven weeks before liver enzyme elevation or the onset of clinical symptoms. The serology of 50% of affected patients will be positive three weeks after acute onset, while at the seventeen week mark only 10% will remain positive. There is evidence of a “window” stage where the hepatitis B surface antigen has become negative and the patient has not yet developed the hepatitis B surface antibody. The chronic carrier state is indicated by the persistence of hepatitis B surface antigen over six months and longer (even years) while never seroconverting to hepatitis B surface antibody. The reference range is negative. The detection of the hepatitis B surface antigen establishes the presence of infection and implies infectivity. ICD-9-CM Codes that Support Medical Necessity The Hepatitis B surface antigen (HBsAg) is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 783.0 787.02 789.1 790.4 791.9 792.1 V01.71 - V01.79 V02.61 V45.11* ANOREXIA NAUSEA ALONE HEPATOMEGALY NONSPECIFIC ELEVATION OF LEVELS OF TRANSAMINASE OR LACTIC ACID DEHYDROGENASE (LDH) OTHER NONSPECIFIC FINDINGS ON EXAMINATION OF URINE NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS CONTACT OR EXPOSURE TO VARICELLA - CONTACT OR EXPOSURE TO OTHER VIRAL DISEASES CARRIER OR SUSPECTED CARRIER OF HEPATITIS B RENAL DIALYSIS STATUS Note: Billing for Hepatitis B Surface Antigen for ESRD beneficiaries requires dual diagnoses. Please submit codes 403.01, 403.11, 404.02, 404.03, 404.12, 404.13, or 585.4-585.6 and *V45.1 to report the approved indication. * According to the ICD-9CM book, Diagnosis code V45.1 is a secondary diagnosis code and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Ionized Calcium (L29206) Data Source: http://www.cms.gov CPT Code 82330 LCD Description: The bulk of body calcium (98%-99%) is stored in the skeleton and teeth, which act as huge reservoirs for maintaining the blood levels of calcium. Ionized calcium is a cation that circulates freely in the bloodstream and comprises 46-50% of all circulating calcium. Only the ionized calcium can be used by the body in such vital processes as muscular contraction, cardiac function, transmission of nerve impulses, and blood clotting. Ionized calcium is considered a more sensitive and accurate indicator for many operative procedures and disease processes. A normal serum ionized calcium for an adult is 4.65 - 5.28 mg/dl. ICD-9-CM Codes that Support Medical Necessity The Ionized Calcium test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference. 038.0 - 038.9 252.00 - 252.08 252.1 259.3 275.2 275.41 275.42 275.49 278.4 293.83 298.9 458.9 577.0 577.1 585.1 - 585.9 586 588.81 - 588.89 733.90 780.60 STREPTOCOCCAL SEPTICEMIA - UNSPECIFIED SEPTICEMIA HYPERPARATHYROIDISM, UNSPECIFIED - OTHER HYPERPARATHYROIDISM HYPOPARATHYROIDISM ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED DISORDERS OF MAGNESIUM METABOLISM HYPOCALCEMIA HYPERCALCEMIA OTHER DISORDERS OF CALCIUM METABOLISM HYPERVITAMINOSIS D MOOD DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE UNSPECIFIED PSYCHOSIS HYPOTENSION UNSPECIFIED ACUTE PANCREATITIS CHRONIC PANCREATITIS CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED RENAL FAILURE UNSPECIFIED SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) – OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION DISORDER OF BONE AND CARTILAGE UNSPECIFIED FEVER, UNSPECIFIED 780.61 780.62 780.63 780.66 780.79 781.0 781.7 782.4 785.0 786.06 787.01 - 787.04 787.20 - 787.29 788.42 789.06 996.81 V42.0* V45.11* V56.0 FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE POSTPROCEDURAL FEVER POSTVACCINATION FEVER FEBRILE NONHEMOLYTIC TRANSFUSION REACTION OTHER MALAISE AND FATIGUE ABNORMAL INVOLUNTARY MOVEMENTS TETANY JAUNDICE UNSPECIFIED NOT OF NEWBORN TACHYCARDIA UNSPECIFIED TACHYPNEA NAUSEA WITH VOMITING - BILIOUS EMESIS DYSPHAGIA, UNSPECIFIED - OTHER DYSPHAGIA POLYURIA ABDOMINAL PAIN EPIGASTRIC COMPLICATIONS OF TRANSPLANTED KIDNEY KIDNEY REPLACED BY TRANSPLANT RENAL DIALYSIS STATUS AFTERCARE INVOLVING EXTRACORPOREAL DIALYSIS *According to the ICD-9 CM Book, Diagnosis codes V42.0 and V45.11 are secondary diagnosies codes. These should be billed alone. A primary Diagnosis code should be billed in addition to the secondary diagnoses codes. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Magnesium (L29217) 1 of 3 Data Source: http://www.cms.gov CPT Code 83735 LCD Description:.. Magnesium is an important activator ion, participating in the function of many enzymes involved in phosphate transfer reactions. Most of the magnesium found within the body exists intracellularly, and since most of it is bound to adenosine triphosphate, this electrolyte is critical in nearly all metabolic processes and most organ functions. Magnesium exerts physiologic effects on the nervous system resembling those of calcium, acting directly upon the myoneural junction. Furthermore, magnesium acts as a cofactor that modifies the activity of many enzymes. Carbohydrate, protein, and nucleic acid metabolism depend on magnesium. Excretion of magnesium is via the kidney, and altered concentration of magnesium in the plasma usually provokes an associated alteration of calcium and potassium. The normal plasma concentration of magnesium is 1.5-2.5 meq/L, with about one-third bound to protein and two-thirds existing as free cation. ICD-9-CM Codes that Support Medical Necessity: The Magnesium test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 242.00 - 242.91 250.10 - 250.13 250.20 - 250.23 250.30 - 250.33 250.40 - 250.43 250.50 - 250.53 250.60 - 250.63 250.70 - 250.73 250.80 – 250.83 TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT 252.00 – 252.08 STATED AS UNCONTROLLED - DIABETES WITH KETOACIDOSIS, 252.8 TYPE I [JUVENILE TYPE], UNCONTROLLED 253.6 DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, 255.10 - 255.14 NOT STATED AS UNCONTROLLED - DIABETES WITH HYPEROSMOLARITY TYPE [JUVENILE TYPE], UNCONTROLLED 255.41 DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, 255.42 NOT STATED AS UNCONTROLLED - DIABETES WITH OTHER COMA, 259.3 TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH RENAL MANIFESTATIONS, 260 261 TYPE I [JUVENILE TYPE], UNCONTROLLED 262 DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR 263.0 UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH 263.8 OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED 275.2 DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR 275.40 - 275.49 UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], 276.2 UNCONTROLLED 276.4 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR 276.50 - 276.52 UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH 276.7 – 276.8 PERIPHERALCIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], 293.0, 293.1 UNCONTROLLED DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE ii OR UNSPECIFIED TYPE, NOT STATED, NOT CONTROLLED DIABETES WITH OTHER MANIFESTATIONS, TYPE I [JUVENILE], UNCONTROLLED HYPOPARATHYROIDISM OTHER SPECIFIED DISORDERS OF PARATHYROID GLAND OTHER DISORDERS OF NEUROHYPOPHYSIS HYPERALDOSTERONISM, UNSPECIFIED - OTHER SECONDARY ALDOSTERONISM GLUCOCORTICOID DEFICIENCY MINERALOCORTICOID DEFICIENCY ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED KWASHIORKOR NUTRITIONAL MARASMUS OTHER SEVERE PROTEIN-CALORIE MALNUTRITION MALNUTRITION OF MODERATE DEGREE OTHER PROTEIN-CALORIE MALNUTRITION DISORDERS OF MAGNESIUM METABOLISM UNSPECIFIED DISORDER OF CALCIUM METABOLISM OTHER DISORDERS OF CALCIUM METABOLISM ACIDOSIS MIXED ACID-BASE BALANCE DISORDER VOLUME DEPL HYPERPOTASSEMIA DELIRIUM * According to the ICD-9-CM book, Diagnosis codes V42.0, V42.7 and V58.69 are secondary diagnosis codes and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Magnesium (L29217) 2 of 3 Data Source: http://www.cms.gov CPT Code 83735 LCD Description:.. Magnesium is an important activator ion, participating in the function of many enzymes involved in phosphate transfer reactions. Most of the magnesium found within the body exists intracellularly, and since most of it is bound to adenosine triphosphate, this electrolyte is critical in nearly all metabolic processes and most organ functions. Magnesium exerts physiologic effects on the nervous system resembling those of calcium, acting directly upon the myoneural junction. Furthermore, magnesium acts as a cofactor that modifies the activity of many enzymes. Carbohydrate, protein, and nucleic acid metabolism depend on magnesium. Excretion of magnesium is via the kidney, and altered concentration of magnesium in the plasma usually provokes an associated alteration of calcium and potassium. The normal plasma concentration of magnesium is 1.5-2.5 meq/L, with about one-third bound to protein and two-thirds existing as free cation. ICD-9-CM Codes that Support Medical Necessity: The Magnesium test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 579.3 579.8 584.5 - 584.9 585.1 - 585.9 588.81 - 588.89 593.81 643.00 - 643.83 646.80 - 646.84 728.87 728.88 728.89 763.81 - 763.89 780.01 780.02 780.09 780.2 780.31 - 780.39 OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION OTHER SPECIFIED INTESTINAL MALABSORPTION ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS ACUTE KIDNEY FAILURE, UNSPECIFIED CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE UNSPECIFIED SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION VASCULAR DISORDERS OF KIDNEY MILD HYPEREMESIS GRAVIDARUM UNSPECIFIED AS TO EPISODE OF CARE - OTHER VOMITING COMPLICATING PREGNANCY ANTEPARTUM OTHER SPECIFIED COMPLICATIONS OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE - OTHER SPECIFIED POSTPARTUM COMPLICATIONS MUSCLE WEAKNESS (GENERALIZED) RHABDOMYOLYSIS OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA ABNORMALITY IN FETAL HEART RATE OR RHYTHM BEFORE THE ONSET OF LABOR - OTHER SPECIFIED COMPLICATIONS OF LABOR AND DELIVERY AFFECTING FETUS OR NEWBORN COMA TRANSIENT ALTERATION OF AWARENESS ALTERATION OF CONSCIOUSNESS OTHER SYNCOPE AND COLLAPSE FEBRILE CONVULSIONS (SIMPLE), UNSPECIFIED - OTHER CONVULSIONS 781.0 781.7 783.0 785.0 785.50 - 785.59 787.01 - 787.04 787.91 790.6 794.31 794.4 796.1 799.4 940.0 - 949.5 958.4 995.29 997.1 998.00 - 998.09 V42.0* V42.7* V56.0 V56.8 ABNORMAL INVOLUNTARY MOVEMENTS TETANY ANOREXIA TACHYCARDIA UNSPECIFIED SHOCK UNSPECIFIED - OTHER SHOCK WITHOUT TRAUMA NAUSEA WITH VOMITING - BILIOUS EMESIS DIARRHEA OTHER ABNORMAL BLOOD CHEMISTRY NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM (ECG) (EKG) NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF KIDNEY ABNORMAL REFLEX CACHEXIA CHEMICAL BURN OF EYELIDS AND PERIOCULAR AREA DEEP NECROSIS OF UNDERLYING ISSUES DUE TO BURN (DEEP THIRD DEGREE UNSPECIFIED SITE WITH LOSS OF A BODY PART TRAUMATIC SHOCK UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE CARDIAC COMPLICATIONS NOT ELSEWHERE CLASSIFIED POSTOPERATIVE SHOCK, UNSPECIFIED – POSTOPERATIVE SHOCK, OTHER KIDNEY REPLACED BY TRANSPLANT LIVER REPLACED BY TRANSPLANT AFTERCARE INVOLVING EXTRACORPOREAL DIALYSIS AFTERCARE INVOLVING OTHER DIALYSIS This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Magnesium (L29217) 3 of 3 Data Source: http://www.cms.gov CPT Code 83735 LCD Description:.. Magnesium is an important activator ion, participating in the function of many enzymes involved in phosphate transfer reactions. Most of the magnesium found within the body exists intracellularly, and since most of it is bound to adenosine triphosphate, this electrolyte is critical in nearly all metabolic processes and most organ functions. Magnesium exerts physiologic effects on the nervous system resembling those of calcium, acting directly upon the myoneural junction. Furthermore, magnesium acts as a cofactor that modifies the activity of many enzymes. Carbohydrate, protein, and nucleic acid metabolism depend on magnesium. Excretion of magnesium is via the kidney, and altered concentration of magnesium in the plasma usually provokes an associated alteration of calcium and potassium. The normal plasma concentration of magnesium is 1.5-2.5 meq/L, with about one-third bound to protein and two-thirds existing as free cation. ICD-9-CM Codes that Support Medical Necessity: The Magnesium test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 303.90 - 303.93 305.00 - 305.03 307.1 307.51 307.52 333.2 333.3 410.00 - 410.92 424.0 427.0 - 427.89 428.0 458.0 - 458.8 536.2 569.87 577.0 - 577.9 781.7 V56.8 V58.11 V58.69* OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE UNSPECIFIED DRINKING BEHAVIOR - OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE IN REMISSION NONDEPENDENT ALCOHOL ABUSE UNSPECIFIED DRINKING BEHAVIOR NONDEPENDENT ALCOHOL ABUSE IN REMISSION ANOREXIA NERVOSA BULIMIA NERVOSA PICA MYOCLONUS TICS OF ORGANIC ORIGIN ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE MITRAL VALVE DISORDERS PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - OTHER SPECIFIED CARDIAC DYSRHYTHMIAS CONGESTIVE HEART FAILURE UNSPECIFIED ORTHOSTATIC HYPOTENSION - OTHER SPECIFIED HYPOTENSION PERSISTENT VOMITING VOMITING OF FECAL MATTER ACUTE PANCREATITIS - UNSPECIFIED DISEASE OF PANCREAS TETANY AFTERCARE INVOLVING OTHER DIALYSIS ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS * According to the ICD-9-CM book, Diagnosis codes V42.0, V42.7 and V58.69 are secondary diagnosis codes and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Non-Covered ICD-9-CM Codes for All NCD Edits Florida Data Source: http://www.cms.gov This section lists codes that are never covered. If a code from this section is given as the reason for the test, the test may be billed to the Medicare beneficiary without billing Medicare first because the service is not covered by statute, in most instances because it is performed for screening purposes and is not within an exception. The beneficiary, however, does have a right to have the claim submitted to Medicare, upon request. 798.0 - 798.9 V18.51 V60.81 V74.0 - V74.9 V77.2 - V77.99 V15.85 V18.59 V60.89 V75.0 - V75.9 V78.0 - V78.9 V16.1 V18.61 V60.9 V76.0 V79.0 - V79.9 V16.2 V18.69 V62.0 – V62.1 V76.3 V80.01 V16.40 V18.7 - V18.9 V65.0 V76.42 - V76.43 V80.09 V16.50 - V16.59 V19.0 - V19.8 V65.11 V76.45 - V76.47 V80.1 - V80.3 V16.6 V20.0 - V20.2 V65.19 V76.49 V81.3 - V81.6 V16.7 V20.31-V20.32 V68.0 - V68.9 V76.50 V82.0 - V82.6 V16.8 V28.0 - V28.9 V70.0 - V70.9 V76.52 V82.71 V16.9 V50.0 - V50.9 V73.0 - V73.6 V76.81 V82.79 V17.0 - V17.89 V53.2 V73.81 V76.89 V82.81 V18.0 – V18.4 V60.0 –V60.6 V73.88 - V73.89 V76.9 V82.89 V73.98 – V73.99 V77.0 V82.9 This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/6/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Parathormone, (Parathyroid Hormone) (L29251) 1 of 2 Data Source: http://www.cms.gov CPT Code 83970 LCD Description:. Normally, PTH release is regulated by a negative feedback mechanism involving serum calcium. Normal or elevated circulating calcium (especially the ionized form) inhibits PTH release; a decrease in calcium ions stimulates PTH release. The overall effect of PTH is to raise plasma levels of calcium while lowering phosphorus levels by stimulating osteoclasts and osteocytes to mobilize both calcium and phosphorus from bone; by acting on renal tubular cells to promote calcium reabsorption and phosphorus excretion; and by promoting intestinal absorption of calcium. There are three molecular forms of PTH: (1) intact, also called native or glandular hormone; (2) multiple NH2-terminal fragments; and (3) COOHterminal fragments. Different laboratories assay the three different parts of the PTH molecule. The intact hormone assay most clearly differentiates hyperparathyroidism from nonparathyroid hypercalcemia. The N-terminal (mid-region) fragment contains the active portion of the molecule, but these assays may not measure intact hormone. The C-terminal fragment contains an inactive portion of the molecule; it is the next best choice of assays if the intact hormone assay is not available. The C-terminal fragment is the oldest and most widely available assay. Normal serum PTH levels vary, depending on the laboratory but are typically as follows: Intact PTH: 10 to 65 pg/ml; N-terminal fraction: 8 to 24 pg/ml; and C-terminal fraction: 0 to 340 pg/ml. The PTH is normally measured concomitantly with serum calcium levels. Abnormally elevated PTH values may indicate primary, secondary, or tertiary hyperparathyroidism. Abnormally low PTH levels may result from hypoparathyroidism and from certain malignant diseases such as squamous cell carcinoma of the lung, renal carcinoma, pancreatic carcinoma, or ovarian carcinoma ICD-9-CM Codes that Support Medical Necessity The Parathormone (Parathyroid Hormone) is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 227.1 252.00 - 252.08 252.1 259.3 275.2 275.3 275.41 275.42 275.49 BENIGN NEOPLASM OF PARATHYROID GLAND HYPERPARATHYROIDISM, UNSPECIFIED - OTHER HYPERPARATHYROIDISM HYPOPARATHYROIDISM ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED DISORDERS OF MAGNESIUM METABOLISM DISORDERS OF PHOSPHORUS METABOLISM HYPOCALCEMIA HYPERCALCEMIA OTHER DISORDERS OF CALCIUM METABOLISM 278.4 293.0 293.83 585.1 - 585.9 586 588.81 - 588.89 728.85 733.00 733.01 HYPERVITAMINOSIS D DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE MOOD DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED RENAL FAILURE UNSPECIFIED SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION SPASM OF MUSCLE OSTEOPOROSIS UNSPECIFIED SENILE OSTEOPOROSIS * According to the ICD-9-CM book, diagnosis code V42.0 is a secondary diagnosis code and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Parathormone, (Parathyroid Hormone) (L29251) 2 of 2 Data Source: http://www.cms.gov CPT Code 83970 LCD Description:. Normally, PTH release is regulated by a negative feedback mechanism involving serum calcium. Normal or elevated circulating calcium (especially the ionized form) inhibits PTH release; a decrease in calcium ions stimulates PTH release. The overall effect of PTH is to raise plasma levels of calcium while lowering phosphorus levels by stimulating osteoclasts and osteocytes to mobilize both calcium and phosphorus from bone; by acting on renal tubular cells to promote calcium reabsorption and phosphorus excretion; and by promoting intestinal absorption of calcium. There are three molecular forms of PTH: (1) intact, also called native or glandular hormone; (2) multiple NH2-terminal fragments; and (3) COOHterminal fragments. Different laboratories assay the three different parts of the PTH molecule. The intact hormone assay most clearly differentiates hyperparathyroidism from nonparathyroid hypercalcemia. The N-terminal (mid-region) fragment contains the active portion of the molecule, but these assays may not measure intact hormone. The C-terminal fragment contains an inactive portion of the molecule; it is the next best choice of assays if the intact hormone assay is not available. The C-terminal fragment is the oldest and most widely available assay. Normal serum PTH levels vary, depending on the laboratory but are typically as follows: Intact PTH: 10 to 65 pg/ml; N-terminal fraction: 8 to 24 pg/ml; and C-terminal fraction: 0 to 340 pg/ml. The PTH is normally measured concomitantly with serum calcium levels. Abnormally elevated PTH values may indicate primary, secondary, or tertiary hyperparathyroidism. Abnormally low PTH levels may result from hypoparathyroidism and from certain malignant diseases such as squamous cell carcinoma of the lung, renal carcinoma, pancreatic carcinoma, or ovarian carcinoma ICD-9-CM Codes that Support Medical Necessity The Parathormone (Parathyroid Hormone) is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 733.02 733.90 780.79 781.0 781.7 787.01 - 787.04 787.20 - 787.29 788.42 V42.0* V67.00 IDIOPATHIC OSTEOPOROSIS DISORDER OF BONE AND CARTILAGE UNSPECIFIED OTHER MALAISE AND FATIGUE ABNORMAL INVOLUNTARY MOVEMENTS TETANY NAUSEA WITH VOMITING - BILIOUS EMESIS DYSPHAGIA, UNSPECIFIED - OTHER DYSPHAGIA POLYURIA KIDNEY REPLACED BY TRANSPLANT FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED/OTHER SURGERY * According to the ICD-9-CM book, diagnosis code V42.0 is a secondary diagnosis code and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Qualitative Drug Screening (L30574) 1 of 2 Data Source: http://www.cms.gov CPT Code 80102, G0431, and G0434 LCD Description: A qualitative drug screen reports the presence of a drug in a blood or urine specimen. A blood or urine sample may be used. Urine is usually the preferred specimen type due to its sensitivity to many common drugs compared to blood specimens. A qualitative drug screen may be indicated when the history is unreliable, with a multiple-drug ingestion, with a patient in delirium or coma, for the identification of specific drugs, and to indicate when antagonists may be used. ICD-9-CM Codes that Support Medical Necessity: Medicare will consider performance of a qualitative drug screen (HCPCS code G0430/G0431) medically reasonable and necessary when the patient presents with suspected drug overdose or suspected drug misuse and one or more of the following indications: 276.2 304.90 345.10 345.11 345.3 345.90 345.91 426.10 426.11 426.12 426.13 426.82 427.0 427.1 518.81 780.01 780.09 780.39 963.0 965.00 ACIDOSIS UNSPECIFIED DRUG DEPENDENCE UNSPECIFIED USE GENERALIZED CONVULSIVE EPILEPSY WITHOUT INTRACTABLE EPILEPSY GENERALIZED CONVULSIVE EPILEPSY WITH INTRACTABLE EPILEPSY GRAND MAL STATUS EPILEPTIC EPILEPSY UNSPECIFIED WITHOUT INTRACTABLE EPILEPSY EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY ATRIOVENTRICULAR BLOCK UNSPECIFIED FIRST DEGREE ATRIOVENTRICULAR BLOCK MOBITZ (TYPE) II ATRIOVENTRICULAR BLOCK OTHER SECOND DEGREE ATRIOVENTRICULAR BLOCK LONG QT SYNDROME PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA PAROXYSMAL VENTRICULAR TACHYCARDIA ACUTE RESPIRATORY FAILURE COMA ALTERATION OF CONSCIOUSNESS OTHER OTHER CONVULSIONS POISONING BY ANTIALLERGIC AND ANTIEMETIC DRUGS POISONING BY OPIUM (ALKALOIDS) UNSPECIFIED 965.01 965.02 965.09 965.1 965.4 POISONING BY HEROIN POISONING BY METHADONE POISONING BY OTHER OPIATES AND RELATED NARCOTICS POISONING BY SALICYLATES POISONING BY AROMATIC ANALGESICS NOT ELSEWHERE CLASSIFIED 965.5 POISONING BY PYRAZOLE DERIVATIVES 965.61 POISONING BY PROPIONIC ACID DERIVATIVES 966.1 POISONING BY HYDANTOIN DERIVATIVES 967.0 POISONING BY BARBITURATES 967.1 POISONING BY CHLORAL HYDRATE GROUP 967.2 POISONING BY PARALDEHYDE 967.3 POISONING BY BROMINE COMPOUNDS 967.4 POISONING BY METHAQUALONE COMPOUNDS 967.5 POISONING BY GLUTETHIMIDE GROUP 967.6 POISONING BY MIXED SEDATIVES NOT ELSEWHERE CLASSIFIED 967.8 POISONING BY OTHER SEDATIVES AND HYPNOTICS 967.9 POISONING BY UNSPECIFIED SEDATIVE OR HYPNOTIC 969.00 - 969.09 POISONING BY ANTIDEPRESSANT, UNSPECIFIED - POISONING BY OTHER ANTIDEPRESSANTS 969.1 POISONING BY PHENOTHIAZINE-BASED TRANQUILIZERS 969.2 POISONING BY BUTYROPHENONE-BASED TRANQUILIZERS *Although designated by the American Association (AMA) as supplementary codes for the purposes of this FCSC Medicare will not require a primary ICD 9 CM code When using V15.81 and V58.69 to bill for approved indication This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Qualitative Drug Screening (L30574) 2 of 2 Data Source: http://www.cms.gov CPT Code 80102, G0431 and G0434 LCD Description: A qualitative drug screen reports the presence of a drug in a blood or urine specimen. A blood or urine sample may be used. Urine is usually the preferred specimen type due to its sensitivity to many common drugs compared to blood specimens. A qualitative drug screen may be indicated when the history is unreliable, with a multiple-drug ingestion, with a patient in delirium or coma, for the identification of specific drugs, and to indicate when antagonists may be used. ICD-9-CM Codes that Support Medical Necessity: Medicare will consider performance of a qualitative drug screen (HCPCS code G0430/G0431) medically reasonable and necessary when the patient presents with suspected drug overdose or suspected drug misuse and one or more of the following indications: 969.3 969.4 969.5 969.6 969.70 - 969.79 969.8 969.9 970.81 - 970.89 972.1 977.9 V15.81* V58.69* V71.09 POISONING BY OTHER ANTIPSYCHOTICS NEUROLEPTICS AND MAJOR TRANQUILIZERS POISONING BY BENZODIAZEPINE-BASED TRANQUILIZERS POISONING BY OTHER TRANQUILIZERS POISONING BY PSYCHODYSLEPTICS (HALLUCINOGENS) POISONING BY PSYCHOSTIMULANT, UNSPECIFIED - POISONING BY OTHER PSYCHOSTIMULANTS POISONING BY OTHER SPECIFIED PSYCHOTROPIC AGENTS POISONING BY UNSPECIFIED PSYCHOTROPIC AGENT POISONING BY COCAINE - POISONING BY OTHER CENTRAL NERVOUS SYSTEM STIMULANTS POISONING BY CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION POISONING BY UNSPECIFIED DRUG OR MEDICINAL SUBSTANCE PERSONAL HISTORY OF NONCOMPLIANCE WITH MEDICAL TREATMENT PRESENTING HAZARDS TO HEALTH LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS OBSERVATION OF OTHER SUSPECTED MENTAL CONDITION *Although designated by the American Association (AMA) as supplementary codes for the purposes of this FCSC Medicare will not require a primary ICD 9 CM code When using V15.81 and V58.69 to bill for approved indication This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/2013 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Sedimentation Rate, Erythrocyte (L29277) 1 of 2 Data Source: http://www.cms.gov CPT Codes 85651 and 85652 LCD Description(85651):.The erythrocyte sedimentation rate (ESR) is a sensitive but nonspecific test that is frequently the earliest indicator of disease when other chemical or physical signs are normal. It is most often used as a gauge for determining the progress and detection of an inflammatory disorder caused by infection, autoimmune mechanisms, or connective tissue disease. LCD Description(85652):.. The frequency with which hepatic function is tested depends upon the clinical situation and generally, upon the time during which a significant (relevant to treatment) change in hepatic function is expected to occur. ICD-9-CM Codes that Support Medical Necessity: The Sedimentation Rate, Erythrocyte test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 200.20 - 200.28 201.00 - 201.98 202.00 - 202.08 202.80 - 202.88 240.0 - 240.9 241.0 - 241.9 242.00 - 242.91 245.0 - 245.9 246.8 279.41 - 279.49 285.29 285.9 362.34 379.91 391.0 391.1 BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE - BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES GOITER SPECIFIED AS SIMPLE - GOITER UNSPECIFIED NONTOXIC UNINODULAR GOITER – UNSPECIFIED NONTOXIC NODULAR GOITER TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC CRISIS OR STORM ACUTE THYROIDITIS - THYROIDITIS UNSPECIFIED OTHER SPECIFIED DISORDERS OF THYROID AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME - AUTOIMMUNE DISEASE, NOT ELSEWHERE CLASSIFIED ANEMIA OF OTHER CHRONIC DISEASE ANEMIA UNSPECIFIED TRANSIENT RETINAL ARTERIAL OCCLUSION PAIN IN OR AROUND EYE ACUTE RHEUMATIC PERICARDITIS ACUTE RHEUMATIC ENDOCARDITIS 391.2 391.8 410.00 - 410.92 446.0 446.5 447.6 556.0 - 556.9 696.0 710.0 710.1 710.2 710.4 710.9 714.0 ACUTE RHEUMATIC MYOCARDITIS OTHER ACUTE RHEUMATIC HEART DISEASE ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIEDACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE POLYARTERITIS NODOSA GIANT CELL ARTERITIS ARTERITIS UNSPECIFIED ULCERATIVE (CHRONIC) ENTEROCOLITIS VULCERATIVE COLITIS UNSPECIFIED PSORIATIC ARTHROPATHY SYSTEMIC LUPUS ERYTHEMATOSUS SYSTEMIC SCLEROSIS SICCA SYNDROME POLYMYOSITIS UNSPECIFIED DIFFUSE CONNECTIVE TISSUE DISEASE RHEUMATOID ARTHRITIS *According to the ICD 9-CM Book, diagnosis codes E933.1, E935.6 and E947.2 are secondary diagnosis and must not be billed as the primary diagnosis This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/14 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Sedimentation Rate, Erythrocyte (L29277) 2 of 2 Data Source: http://www.cms.gov CPT Codes 85651 and 85652 LCD Description(85651):.The erythrocyte sedimentation rate (ESR) is a sensitive but nonspecific test that is frequently the earliest indicator of disease when other chemical or physical signs are normal. It is most often used as a gauge for determining the progress and detection of an inflammatory disorder caused by infection, autoimmune mechanisms, or connective tissue disease. LCD Description(85652):.. The frequency with which hepatic function is tested depends upon the clinical situation and generally, upon the time during which a significant (relevant to treatment) change in hepatic function is expected to occur. ICD-9-CM Codes that Support Medical Necessity: The Sedimentation Rate, Erythrocyte test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 714.1 714.2 714.30 714.81 714.9 716.59 719.49 720.0 725 729.1 733.99 783.21 784.0 E933.1* E933.8* E935.6* E947.2* V10.72 FELTY'S SYNDROME OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS RHEUMATOID LUNG UNSPECIFIED INFLAMMATORY POLYARTHROPATHY UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING MULTIPLE SITES PAIN IN JOINT INVOLVING MULTIPLE SITES ANKYLOSING SPONDYLITIS POLYMYALGIA RHEUMATICA MYALGIA AND MYOSITIS UNSPECIFIED OTHER DISORDERS OF BONE AND CARTILAGE LOSS OF WEIGHT HEADACHE ANTINEOPLASTIC AND IMMUNOSUPPRESSIVE DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE OTHER SYSTEMIC AGENTS NOT ELSEWHERE CLASSIFIED CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE ANTIRHEUMATICS (ANTIPHLOGISTICS) CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE ANTIDOTES AND CHELATING AGENTS NOT ELSEWHERE CLASSIFIED CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE PERSONAL HISTORY OF HODGKIN'S DISEASE *According to the ICD 9-CM Book, diagnosis codes E933.1, E935.6 and E947.2 are secondary diagnosis and must not be billed as the primary diagnosis This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Serum Phosphorus 1 of 4 (L29278) Data Source: http://www.cms.gov CPT Code 84100 LCD Description: Phosphorus is a non-metallic chemical element. Most of the body’s phosphorus is combined with calcium within the skeleton; however, approximately 15% of phosphorus exists in the blood as a phosphate salt. Phosphates help store and utilize body energy. Additionally, they help regulate calcium levels, carbohydrate and lipid metabolism, and acid-base balance. Vitamin D is important in the absorption and metabolism of phosphorus. Phosphorus levels are determined by calcium metabolism, parathyroid hormone, and to a lesser degree by intestinal absorption. Normal serum phosphorus is 2.5-4.5 mg/dl. Serum phosphate levels help to detect endocrine, skeletal, and calcium disorders, and aid in the diagnosis of renal disorders and acid-base imbalance. ICD-9-CM Codes that Support Medical Necessity: The Serum Phosphorus test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 135 170.0 - 170.9 198.5 203.00 - 203.02 238.6 252.00 - 252.08 260 261 262 263.0 - 263.9 268.0 - 268.9 275.2 275.3 275.40 - 275.49 293.1 298.9 348.30 - 348.39 276.0 - 276.9 278.4 278.8 283.9 287.0 - 287.9 SARCOIDOSIS MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE - MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MULTIPLE MYELOMA, IN RELAPSE NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS HYPERPARATHYROIDISM, UNSPECIFIED - OTHER HYPERPARATHYROIDISM KWASHIORKOR NUTRITIONAL MARASMUS OTHER SEVERE PROTEIN-CALORIE MALNUTRITION MALNUTRITION OF MODERATE DEGREE - UNSPECIFIED PROTEIN-CALORIE MALNUTRITION RICKETS ACTIVE - UNSPECIFIED VITAMIN D DEFICIENCY DISORDERS OF MAGNESIUM METABOLISM DISORDERS OF PHOSPHORUS METABOLISM UNSPECIFIED DISORDER OF CALCIUM METABOLISM - OTHER DISORDERS OF CA293.0 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE SUBACUTE DELIRIUM UNSPECIFIED PSYCHOSIS ENCEPHALOPATHY UNSPECIFIED - OTHER ENCEPHALOPATHYLCIUM METABOLISM HYPEROSMOLALITY AND/OR HYPERNATREMIA - ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED HYPERVITAMINOSIS D OTHER HYPERALIMENTATION ACQUIRED HEMOLYTIC ANEMIA UNSPECIFIED ALLERGIC PURPURA - UNSPECIFIED HEMORRHAGIC CONDITIONS This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Serum Phosphorus 2 of 4 (L29278) Data Source: http://www.cms.gov CPT Code 84100 LCD Description: Phosphorus is a non-metallic chemical element. Most of the body’s phosphorus is combined with calcium within the skeleton; however, approximately 15% of phosphorus exists in the blood as a phosphate salt. Phosphates help store and utilize body energy. Additionally, they help regulate calcium levels, carbohydrate and lipid metabolism, and acid-base balance. Vitamin D is important in the absorption and metabolism of phosphorus. Phosphorus levels are determined by calcium metabolism, parathyroid hormone, and to a lesser degree by intestinal absorption. Normal serum phosphorus is 2.5-4.5 mg/dl. Serum phosphate levels help to detect endocrine, skeletal, and calcium disorders, and aid in the diagnosis of renal disorders and acid-base imbalance. ICD-9-CM Codes that Support Medical Necessity: The Serum Phosphorus test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 293.0 293.1 298.9 348.30 - 348.39 403.01 403.11 404.02 404.03 404.12 404.13 579.0 - 579.9 580.0 - 580.9 581.0 - 581.9 582.0 - 582.9 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE SUBACUTE DELIRIUM UNSPECIFIED PSYCHOSIS ENCEPHALOPATHY UNSPECIFIED - OTHER ENCEPHALOPATHY 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 V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 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, WITHOUT 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 CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY CHRONIC GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Serum Phosphorus 3 of 4 (L29278) Data Source: http://www.cms.gov CPT Code 84100 LCD Description: Phosphorus is a non-metallic chemical element. Most of the body’s phosphorus is combined with calcium within the skeleton; however, approximately 15% of phosphorus exists in the blood as a phosphate salt. Phosphates help store and utilize body energy. Additionally, they help regulate calcium levels, carbohydrate and lipid metabolism, and acid-base balance. Vitamin D is important in the absorption and metabolism of phosphorus. Phosphorus levels are determined by calcium metabolism, parathyroid hormone, and to a lesser degree by intestinal absorption. Normal serum phosphorus is 2.5-4.5 mg/dl. Serum phosphate levels help to detect endocrine, skeletal, and calcium disorders, and aid in the diagnosis of renal disorders and acid-base imbalance. ICD-9-CM Codes that Support Medical Necessity: The Serum Phosphorus test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 583.0 - 583.9 584.5 - 584.9 585.1 - 585.9 586 587 588.0 - 588.9 646.90 728.87 728.88 728.89 728.9 729.1 731.0 733.90 753.9 780.39 782.0 783.0 787.02 790.6 790.7 NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS - ACUTE KIDNEY FAILURE, UNSPECIFIED CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED RENAL FAILURE UNSPECIFIED RENAL SCLEROSIS UNSPECIFIED RENAL OSTEODYSTROPHY - UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION UNSPECIFIED COMPLICATION OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE MUSCLE WEAKNESS (GENERALIZED) RHABDOMYOLYSIS OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA MYALGIA AND MYOSITIS UNSPECIFIED OSTEITIS DEFORMANS WITHOUT BONE TUMOR DISORDER OF BONE AND CARTILAGE UNSPECIFIED UNSPECIFIED CONGENITAL ANOMALY OF URINARY SYSTEM OTHER CONVULSIONS DISTURBANCE OF SKIN SENSATION ANOREXIA NAUSEA ALONE OTHER ABNORMAL BLOOD CHEMISTRY BACTEREMIA This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Serum Phosphorus 4 of 4 (L29278) Data Source: http://www.cms.gov CPT Code 84100 LCD Description: Phosphorus is a non-metallic chemical element. Most of the body’s phosphorus is combined with calcium within the skeleton; however, approximately 15% of phosphorus exists in the blood as a phosphate salt. Phosphates help store and utilize body energy. Additionally, they help regulate calcium levels, carbohydrate and lipid metabolism, and acid-base balance. Vitamin D is important in the absorption and metabolism of phosphorus. Phosphorus levels are determined by calcium metabolism, parathyroid hormone, and to a lesser degree by intestinal absorption. Normal serum phosphorus is 2.5-4.5 mg/dl. Serum phosphate levels help to detect endocrine, skeletal, and calcium disorders, and aid in the diagnosis of renal disorders and acid-base imbalance. ICD-9-CM Codes that Support Medical Necessity: The Serum Phosphorus test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 793.0 793.7 799.21 799.22 799.51 799.52 799.54 799.55 965.1 990 995.84 E858.5* E933.3* E943.0* E944.0 - E944.7* V45.89* NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF MUSCULOSKELETAL SYSTEM NERVOUSNESS IRRITABILITY ATTENTION OR CONCENTRATION DEFICIT COGNITIVE COMMUNICATION DEFICIT PSYCHOMOTOR DEFICIT FRONTAL LOBE AND EXECUTIVE FUNCTION DEFICIT POISONING BY SALICYLATES EFFECTS OF RADIATION UNSPECIFIED ADULT NEGLECT (NUTRITIONAL) ACCIDENTAL POISONING BY WATER MINERAL AND URIC ACID METABOLISM DRUGS ALKALIZING AGENTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE ANTACIDS AND ANTIGASTRIC SECRETION DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE MERCURIAL DIURETICS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE - URIC ACID METABOLISM DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE OTHER POSTSURGICAL STATUS * According to the ICD-9-CM book, Diagnosis codes E858.5, E933.3, E943.0, E944.0-E944.7 and V45.89 are secondary diagnosis codes and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved 07/19/11 Medicare Local Coverage Determination Policy Florida Susceptibility Studies (L29319) Data Source: http://www.cms.gov CPT Code 87181, 87184, 87185, 87186, 87187, 87188 and 87190 LCD Description: Some microorganisms are resistant to certain antimicrobials. Susceptibility testing is often used to determine the likelihood that a particular drug treatment regimen will be effective in eliminating or inhibiting the growth of the infection. A culture of the infected area must be done to obtain the organism for identification and to allow susceptibility testing to be performed if warranted. Referred to by the type of body fluid or cells collected (such as: blood culture, urine culture, sputum culture, wound culture, etc.), the culture involves incubating a sample at body temperature in a nutrient-rich environment. This process promotes the replication of any microorganisms present in the sample. Samples from the skin, stool, or sputum will grow normal flora as well as pathogenic bacteria if they are present. Other body samples, such as blood and urine, are usually sterile; they will show little or no growth unless a pathogenic microorganism is present. ICD-9-CM Codes that Support Medical Necessity: The Susceptibility studies test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 001.0 - 009.3 CHOLERA DUE TO VIBRIO CHOLERAE - DIARRHEA OF PRESUMED INFECTIOUS ORIGIN 010.00 - 018.96 PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - UNSPECIFIED MILIARY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) 020.0 - 027.9 BUBONIC PLAGUE - UNSPECIFIED ZOONOTIC BACTERIAL DISEASE 030.0 - 041.9 LEPROMATOUS LEPROSY (TYPE L) - BACTERIAL INFECTION UNSPECIFIED IN CONDITIONS CLASSIFIED ELSEWHERE AND OF UNSPECIFIED SITE 090.0 - 099.9 EARLY CONGENITAL SYPHILIS SYMPTOMATIC - VENEREAL DISEASE UNSPECIFIED 100.0 - 104.9 LEPTOSPIROSIS ICTEROHEMORRHAGICA - SPIROCHETAL INFECTION UNSPECIFIED 110.0 - 118 DERMATOPHYTOSIS OF SCALP AND BEARD - OPPORTUNISTIC MYCOSES 136.8 OTHER SPECIFIED INFECTIOUS AND PARASITIC DISEASES 139.8 LATE EFFECTS OF OTHER AND UNSPECIFIED INFECTIOUS AND PARASITIC DISEASES V09.80 - V09.81* INFECTION WITH MICROORGANISMS RESISTANT TO OTHER SPECIFIED DRUGS WITHOUT RESISTANCE TO MULTIPLE DRUGS INFECTION WITH MICROORGANISMS RESISTANT TO OTHER SPECIFIED DRUGS WITH RESISTANCE TO MULTIPLE DRUGS *According to the ICD-9 CM Book, diagnosis codes V09.80 and V09.81 are secondary diagnosis codes and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Syphilis (L29416) 1 of 2 Data Source: http://www.cms.gov CPT Codes 86592, 86593 and 86780 LCD Description: The fluorescent treponemal antibody absorption (FTA-abs) test is the most widely employed treponemal test. It is a specific test for the diagnosis of syphilis. The FTA-abs test includes a serum specimen which is absorbed and then tested with immunofluorescence for the antibody to Treponema pallidum, the causative agent of syphilis. FTA-abs is the most sensitive test in all stages of syphilis. The FTA-abs test is of value principally in determining whether a positive nontreponemal antigen test (e.g., Rapid Plasma Reagin [RPR] or Venereal Disease Research Laboratory [VDRL]) is “false positive” or is indicative of syphilis. Because of its great sensitivity, particularly in the late stages of the disease, the FTA-abs test is also of value when there is clinical evidence of syphilis but the nontreponemal serologic test for syphilis is negative. The test is positive in most patients with primary syphilis and in virtually all with secondary syphilis. ICD-9-CM Codes that Support Medical Necessity: The Fluorescent Treponemal Antibody Absorption test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference. 042 053.0 - 053.9 054.0 - 054.9 070.0 - 070.9 078.0 078.10 - 078.19 078.88 079.4 079.50 - 079.59 079.88 090.0 - 090.9 091.0 - 091.9 092.0 - 092.9 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE HERPES ZOSTER WITH MENINGITIS - HERPES ZOSTER WITHOUT COMPLICATION ECZEMA HERPETICUM - HERPES SIMPLEX WITHOUT COMPLICATION VIRAL HEPATITIS A WITH HEPATIC COMA - UNSPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA MOLLUSCUM CONTAGIOSUM VIRAL WARTS UNSPECIFIED - OTHER SPECIFIED VIRAL WARTS OTHER SPECIFIED DISEASES DUE TO CHLAMYDIAE HUMAN PAPILLOMAVIRUS IN CONDITIONS CLASSIFIED ELSEWHERE AND OF UNSPECIFIED SITE RETROVIRUS UNSPECIFIED - OTHER SPECIFIED RETROVIRUS OTHER SPECIFIED CHLAMYDIAL INFECTION EARLY CONGENITAL SYPHILIS SYMPTOMATIC CONGENITAL SYPHILIS UNSPECIFIED GENITAL SYPHILIS (PRIMARY) - UNSPECIFIED SECONDARY SYPHILIS EARLY SYPHILIS LATENT SEROLOGICAL RELAPSE AFTER TREATMENT - EARLY SYPHILIS LATENT UNSPECIFIED 093.0 - 093.9 094.0 - 094.9 095.0 - 095.9 096 097.0 - 097.9 098.0 - 098.89 099.0 - 099.9 104.0 131.00 131.02 131.03 131.09 131.8 131.9 290.10 - 290.13 ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC CARDIOVASCULAR SYPHILIS UNSPECIFIED TABES DORSALIS - NEUROSYPHILIS UNSPECIFIED SYPHILITIC EPISCLERITIS - LATE SYMPTOMATIC SYPHILIS UNSPECIFIED LATE SYPHILIS LATENT LATE SYPHILIS UNSPECIFIED - SYPHILIS UNSPECIFIED GONOCOCCAL INFECTION (ACUTE) OF LOWER GENITOURINARY TRACT - GONOCOCCAL INFECTION OF OTHER SPECIFIED SITES CHANCROID - VENEREAL DISEASE UNSPECIFIED NONVENEREAL ENDEMIC SYPHILIS UROGENITAL TRICHOMONIASIS UNSPECIFIED TRICHOMONAL URETHRITIS TRICHOMONAL PROSTATITIS OTHER UROGENITAL TRICHOMONIASIS TRICHOMONIASIS OF OTHER SPECIFIE TRICHOMONIASIS UNSPECIFIED PRESENILE DEMENTIA UNCOMPLICATED – PRESENILE DEMENTIA WITH DEPRESSIVE FEATURESD SITES This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Syphilis (L29416) 2 or 2 Data Source: http://www.cms.gov CPT Codes 86592, 86593 and 86780 LCD Description: The fluorescent treponemal antibody absorption (FTA-abs) test is the most widely employed treponemal test. It is a specific test for the diagnosis of syphilis. The FTA-abs test includes a serum specimen which is absorbed and then tested with immunofluorescence for the antibody to Treponema pallidum, the causative agent of syphilis. FTA-abs is the most sensitive test in all stages of syphilis. The FTA-abs test is of value principally in determining whether a positive nontreponemal antigen test (e.g., Rapid Plasma Reagin [RPR] or Venereal Disease Research Laboratory [VDRL]) is “false positive” or is indicative of syphilis. Because of its great sensitivity, particularly in the late stages of the disease, the FTA-abs test is also of value when there is clinical evidence of syphilis but the nontreponemal serologic test for syphilis is negative. The test is positive in most patients with primary syphilis and in virtually all with secondary syphilis. ICD-9-CM Codes that Support Medical Necessity: The Fluorescent Treponemal Antibody Absorption test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference. 614.0 - 614.9 ACUTE SALPINGITIS AND OOPHORITIS - UNSPECIFIED NFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS AND TISSUES 293.0 293.1 294.8 296.82 310.1 331.0 331.2 331.9 356.0 356.9 389.10 604.0 604.90 604.91 DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE SUBACUTE DELIRIUM OTHER PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE ATYPICAL DEPRESSIVE DISORDER PERSONALITY CHANGE DUE TO CONDITIONS CLASSIFIED ELSEWHERE ALZHEIMER'S DISEASE SENILE DEGENERATION OF BRAIN CEREBRAL DEGENERATION UNSPECIFIED HEREDITARY PERIPHERAL NEUROPATHY UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY SENSORINEURAL HEARING LOSS UNSPECIFIED ORCHITIS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS WITH ABSCESS ORCHITIS AND EPIDIDYMITIS UNSPECIFIED ORCHITIS AND EPIDIDYMITIS IN DISEASES CLASSIFIED ELSEWHERE 614.0 - 614.9 ACUTE SALPINGITIS AND OOPHORITIS - UNSPECIFIED NFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS AND TISSUES 615.0 - 615.9 ACUTE INFLAMMATORY DISEASES OF UTERUS EXCEPT CERVIX - UNSPECIFIED INFLAMMATORY DISEASE OF UTERUS 616.0 - 616.9 CERVICITIS AND ENDOCERVICITIS - UNSPECIFIED INFLAMMATORY DISEASE OF CERVIX VAGINA AND VULVA 760.2 MATERNAL INFECTIONS AFFECTING FETUS OR NEWBORN 781.2 ABNORMALITY OF GAIT 782.1 RASH AND OTHER NONSPECIFIC SKIN ERUPTION 785.6 ENLARGEMENT OF LYMPH NODES V01.6 CONTACT WITH OR EXPOSURE TO VENEREAL DISEASES V02.7 CARRIER OR SUSPECTED CARRIER OF GONORRHEA V02.8 CARRIER OR SUSPECTED CARRIER OF OTHER VENEREAL DISEASES V08 ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION STATUS This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Total Calcium (L29292) 1 of 3 Data Source: http://www.cms.gov CPT Code 82310 LCD Description: Calcium is a predominantly extracellular cation. It is of great importance in blood coagulation; it gives firmness and rigidity to bones and teeth; it is important in acid-base balance; it is essential for lactation; it is important in activating enzymes; it is essential for the function of nerves and muscles, including the myocardium; and for maintaining the permeability of membranes. Over 98% of body’s calcium is found in the bones and teeth. The serum calcium test is used to evaluate parathyroid function and calcium metabolism by directly measuring the total amount of calcium in the blood. About 50% of blood calcium is ionized; the rest is protein bound (with albumin). The serum calcium level is a measurement of both. The normal adult serum calcium level is between 8.5-10.5mg/dl. ICD-9-CM Codes that Support Medical Necessity: The Total Calcium test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 135 140.0 - 208.92 209.00 - 209.03 209.10 - 209.17 209.20 - 209.29 209.30 - 209.36 252.00 - 252.08 252.1 255.41 255.42 260 - 269.9 275.41 275.42 SARCOIDOSIS MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - UNSPECIFIED LEUKEMIA, IN RELAPSE MALIGNANT CARCINOID TUMOR OF THE SMALL INTESTINE, UNSPECIFIED PORTION - MALIGNANT CARCINOID TUMOR OF THE ILEUM MALIGNANT CARCINOID TUMOR OF THE LARGE INTESTINE, UNSPECIFIED PORTION - MALIGNANT CARCINOID TUMOR OF THE RECTUM MALIGNANT CARCINOID TUMOR OF UNKNOWN PRIMARY SITE - MALIGNANT CARCINOID TUMOR OF OTHER SITES MALIGNANT POORLY DIFFERENTIATED NEUROENDOCRINE CARCINOMA, ANY SITE - MERKEL CELL CARCINOMA OF OTHER SITES HYPERPARATHYROIDISM, UNSPECIFIED - OTHER HYPERPARATHYROIDISM HYPOPARATHYROIDISM GLUCOCORTICOID DEFICIENCY MINERALOCORTICOID DEFICIENCY KWASHIORKOR - UNSPECIFIED NUTRITIONAL DEFICIENCY HYPOCALCEMIA HYPERCALCEMIA 275.49 276.0 - 276.9 278.4 293.0 293.1 293.83 298.9 300.00 - 300.09 368.13 368.2 427.0 - 427.9 519.11 519.19 564.00 - 564.09 577.0 577.1 OTHER DISORDERS OF CALCIUM METABOLISM HYPEROSMOLALITY AND/OR HYPERNATREMIA ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED HYPERVITAMINOSIS D DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE SUBACUTE DELIRIUM MOOD DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE UNSPECIFIED PSYCHOSIS ANXIETY STATE UNSPECIFIED - OTHER ANXIETY STATES VISUAL DISCOMFORT DIPLOPIA PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA CARDIAC DYSRHYTHMIA UNSPECIFIED ACUTE BRONCHOSPASM OTHER DISEASES OF TRACHEA AND BRONCHUS UNSPECIFIED CONSTIPATION - OTHER CONSTIPATION ACUTE PANCREATITIS CHRONIC PANCREATITIS * According to the ICD-9-CM book, Diagnosis codes E934.2, E936.3, E943.3, E944.4, and E944.5 are secondary diagnosis codes and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Total Calcium (L29292) 2 of 3 Data Source: http://www.cms.gov CPT Code 82310 LCD Description: Calcium is a predominantly extracellular cation. It is of great importance in blood coagulation; it gives firmness and rigidity to bones and teeth; it is important in acid-base balance; it is essential for lactation; it is important in activating enzymes; it is essential for the function of nerves and muscles, including the myocardium; and for maintaining the permeability of membranes. Over 98% of body’s calcium is found in the bones and teeth. The serum calcium test is used to evaluate parathyroid function and calcium metabolism by directly measuring the total amount of calcium in the blood. About 50% of blood calcium is ionized; the rest is protein bound (with albumin). The serum calcium level is a measurement of both. The normal adult serum calcium level is between 8.5-10.5mg/dl. ICD-9-CM Codes that Support Medical Necessity: The Total Calcium test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 579.0 - 579.9 580.0 - 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 - 588.9 592.0 728.87 728.88 728.89 728.9 CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS – NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY CHRONIC GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS – CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS - ACUTE KIDNEY FAILURE, UNSPECIFIED CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED RENAL FAILURE UNSPECIFIED RENAL SCLEROSIS UNSPECIFIED RENAL OSTEODYSTROPHY - UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION CALCULUS OF KIDNEY MUSCLE WEAKNESS (GENERALIZED) RHABDOMYOLYSIS OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA * According to the ICD-9-CM book, Diagnosis codes E934.2, E936.3, E943.3, E944.4, and E944.5 are secondary diagnosis codes and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Total Calcium (L29292) 3 of 3 Data Source: http://www.cms.gov CPT Code 82310 LCD Description: Calcium is a predominantly extracellular cation. It is of great importance in blood coagulation; it gives firmness and rigidity to bones and teeth; it is important in acid-base balance; it is essential for lactation; it is important in activating enzymes; it is essential for the function of nerves and muscles, including the myocardium; and for maintaining the permeability of membranes. Over 98% of body’s calcium is found in the bones and teeth. The serum calcium test is used to evaluate parathyroid function and calcium metabolism by directly measuring the total amount of calcium in the blood. About 50% of blood calcium is ionized; the rest is protein bound (with albumin). The serum calcium level is a measurement of both. The normal adult serum calcium level is between 8.5-10.5mg/dl. ICD-9-CM Codes that Support Medical Necessity: The Total Calcium test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 729.82 733.90 780.01 780.09 780.1 780.39 780.79 781.0 781.7 782.0 783.0 783.5 785.59 787.01 - 787.04 787.20 - 787.29 788.42 788.43 789.00 CRAMP OF LIMB DISORDER OF BONE AND CARTILAGE UNSPECIFIED COMA ALTERATION OF CONSCIOUSNESS OTHER HALLUCINATIONS OTHER CONVULSIONS OTHER MALAISE AND FATIGUE ABNORMAL INVOLUNTARY MOVEMENTS TETANY DISTURBANCE OF SKIN SENSATION ANOREXIA POLYDIPSIA OTHER SHOCK WITHOUT TRAUMA NAUSEA WITH VOMITING - BILIOUS EMESIS DYSPHAGIA, UNSPECIFIED - OTHER DYSPHAGIA POLYURIA NOCTURIA ABDOMINAL PAIN UNSPECIFIED SITE E934.2* E936.3* E943.3* E944.4* E944.5* ANTICOAGULANTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE OTHER AND UNSPECIFIED ANTICONVULSANTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE OTHER CATHARTICS INCLUDING INTESTINAL ATONIA DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE OTHER DIURETICS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE ELECTOLYTIC CALORIC AND WATER-BALANCE AGENTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE * According to the ICD-9-CM book, Diagnosis codes E934.2, E936.3, E943.3, E944.4, and E944.5 are secondary diagnosis codes and should not be billed as the primary diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Florida Vitamin D; 25 Hydroxy, includes Fraction(s) if performed (L30868) CPT Code 82306 Data Source: http://www.cms.gov LCD Description: Vitamin D, a group of fat-soluble prohormones, is an essential vitamin. There are two major types of Vitamin D (Vitamin D2 and Vitamin D3) which are collectively known as calciferol. They are essential for promoting calcium absorption and maintaining adequate serum calcium and phosphate concentrations to enable mineralization of bone and prevent hypocalcemic conditions. Vitamin D2 (ergocalciferol) is obtained from foods of plant origin and vitamin D3 (cholecalciferol) is obtained from foods of animal origin and ultraviolet light-stimulated conversion of 7dehydrocholestral in the skin. Vitamin D is stored in the human body as calcidiol (25-hydroxyvitamin D). Serum concentration of 25(OH) D is the best indicator of vitamin D status. Vitamin D deficiencies are the result of dietary inadequacy, impaired absorption and use, increased requirement, or increased excretion. Vitamin D deficiency can occur when usual intake is lower than recommended levels over a period of time, or when exposure to sunlight is limited. Vitamin D deficiency can also result from the inability of the kidneys to convert the vitamin D to its active form. Vitamin D toxicity can cause symptoms including nausea, vomiting, poor appetite, constipation, weakness, and weight loss as well as elevation in the blood level of calcium which in turn can lead to mental status changes, and heart rhythm abnormalities. ICD-9-CM Codes that Support Medical Necessity: The Vitamin D test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference. 252.00 252.01 252.02 252.08 252.1 268.0 268.2 268.9 275.3 275.41 275.42 278.4 571.2 571.5 HYPERPARATHYROIDISM, UNSPECIFIED PRIMARY HYPERPARATHYROIDISM SECONDARY HYPERPARATHYROIDISM, NON-RENAL OTHER HYPERPARATHYROIDISM HYPOPARATHYROIDISM RICKETS ACTIVE OSTEOMALACIA UNSPECIFIED UNSPECIFIED VITAMIN D DEFICIENCY DISORDERS OF PHOSPHORUS METABOLISM HYPOCALCEMIA HYPERCALCEMIA HYPERVITAMINOSIS D ALCOHOLIC CIRRHOSIS OF LIVER CIRRHOSIS OF LIVER WITHOUT ALCOHOL 571.6 579.0 - 579.9 585.3 585.4 585.5 585.6 588.81 733.00 733.01 733.02 733.03 733.09 733.90 BILIARY CIRRHOSIS CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) OSTEOPOROSIS UNSPECIFIED SENILE OSTEOPOROSIS IDIOPATHIC OSTEOPOROSIS DISUSE OSTEOPOROSIS OTHER OSTEOPOROSIS DISORDER OF BONE AND CARTILAGE UNSPECIFIED This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/5/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved