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2013
Billing Guide
For questions or more information,
please contact your Billing Coordinator
CLS 2013 BILLING GUIDE: TABLE OF CONTENTS
Page
Introduction ..1
Key Points for Diagnosis Coding .. 2
Medicare Billing 3-13
Successful Laboratory Requisitions
Documentation Requests
Advance Beneficiary Notices
Medicare Secondary Payor
United Healthcare Hepatitis Screening Limitations.... 14-19
Medicare Coverage Limitation Resources 20-28
NCD-LCD Test Code & Price List
Investigation Test Code & Price List
Frequency Test List (NCD)
Frequency Test List (LCD)
Always Non-Covered ICD9-CM Codes
Medicare NCD & LCD Table of Contents ..29-30
Medicare NCD & LCD Listings .31-105
Common ICD-9 Codes ....106-108
INTRODUCTION
The Importance of Diagnosis Codes
In today's regulated healthcare climate, diagnosis codes are mandatory. When
requisitions arrive without a valid and covered code or a signed waiver (if
necessary), the Lab might not be reimbursed for our services. Please assist us
by providing this required information at the time you order the test. if you have
any questions regarding this issue, please contact your service representative
or your billing coordinator.
The Balanced Budget Act of 1997 requires physicians to provide diagnostic or
other medical information when ordering services furnished by another entity in
order for payment to be made to the entity furnishing the service. Colorado
Laboratory Services (CLS) is not allowed to determine what code should be
used for the laboratory services. Only the ordering physician/authorized
provider is authorized to determine the reason that the test is ordered. CLS is
also not allowed to routinely accept orders where Advance Beneficiary Notices
(ABNs) are not collected when necessary, or routinely write off tests where an
ABN is not obtained. This may be considered "inducement" under government
regulations. However, to assist the physician's office in determining whether an
ABN may be needed, CLS provides ABN assistance through our website
www.clslaboratory.com which will help the physician's staff to determine
whether an ABN is required. In addition, CLS provides electronic access to
National and Local Coverage Decision (NCD and LCD) information.
We are pleased to provide various tools designed to help you. These include
staff training, waiver (ABN) forms, waiting room signs, etc.
1
April 2013
Key Points for Diagnosis Coding
All requisitions must provide proof of “medical necessity” for each test ordered in the
form of ICD-9 codes, narrative diagnoses or symptoms.
If the alpha-numeric “ICD-9” code is not known, a narrative diagnosis (full
description or abbreviation) may be written on the requisition.
Example: If the patient's chart indicates atrial fibrillation, but the ICD-9 (427.31) is not known, writing“AFib” on the requisition is acceptable.
**IMPORTANT NOTE: If the patient has Medicare coverage and a Limited Coverage Test is ordered,
the patient will have to sign an Advance Beneficiary Notice (ABN) if only a narrative is provided.
Diagnosis codes can either be actual diagnoses, current symptoms or abnormal test
results.
Example: The patient has been diagnosed w/ hypothyroidism and the provider orders a TSH,
hypothyroidism (244.9) would be the appropriate diagnosis (ICD-9) assigned.
Example: The patient has been experiencing fatigue and weight gain. The provider wants to run a TSH
to see if the patient is hypothyroid. In this case, fatigue (780.79) and weight gain (783.1) would be the
appropriate narratives or codes to assign.
Example: The patient’s lab results come back w/ an elevated glucose (790.29), a low HCT (285.9) and
an abnormality of their UA (791.9). As a result, the provider adds on a Glycohemoglobin (HgbA1C), an
Iron or Ferritin and a Urine Culture. Therefore the “medical necessity” is proven in the abnormal labs (be
specific), not the original diagnosis. This, again, can be given as either a narrative diagnosis or an ICD9 code.
“RULE OUT”, “POSSIBLE” or “SUSPECTED” are not codeable descriptions.
In the above example, rather than considering "ruling out" hypothyroidism, the symptoms which are
causing the provider to believe that this might be the problem, i.e. fatigue and weight gain, should be
provided.
V58.61 is for anticoagulant monitoring and V58.69 is for monitoring of other
medications. These codes are acceptable by Medicare, but they cannot be
interchanged.
When ordering Medication Levels it is still necessary to provide a medically
necessary diagnosis, symptom or “med monitoring” code (V58.61, V58.69).
Although it may be obvious that the patient is on medication, Medicare does not allow
turning a test order into an ICD-9 code.
2
April 2013
Medicare
Billing
3
April 2013
Successful Laboratory Requisitions, Medicare Billing
The following Medicare billing requirements will assist you to
accurately complete laboratory requisitions. The objective is to
minimize recurring phone calls to our valued clients and service
center employees. Thank you for your attention to detail.
When billing Medicare, the following italicized information is always
required on the laboratory requisition. The additional information is
essential for accurate billing.
1. Patient's full name
2. Patient's sex
3. Patient's date of birth
4. Patient's phone number
5. Patient's full address
6. Ordering provider full name
7. Ordering provider signature
8. Date and time of collection and fasting status
9. Who is to be billed (circle Medicare)
10. Patient's Social Security Number (optional)
11. Insurance ID number (Medicare HIC # + Prefix or suffix
character(s))
12. Marked Test(s) being ordered with appropriate and valid ICD9 for every test ordered
13. When indicated, a signed and dated ABN-with test(s) listed,
reason(s) specified for possible denial and estimated cost of
test(s) with the patient checking the option desired and the
patient signing and dating the ABN.
4
April 2013
Successful Laboratory Requisitions, Medicare Billing
5
April 2013
Documentation Requests, Medicare Billing
We, as the Laboratory, perform tests requested for your patients who have Medicare.
We are required, by law, to provide documentation if requested by the Comprehensive
Error Rate Testing (CERT) program by CMS. CERT reviews claims, on a postpayment review of claims, submitted by our laboratory. These claims could be audited
for documentation to support the rendering/billing provider indicated on the claim.
During the audit process, if documentation is needed, the physician or supplier (lab)
must provide the required documentation within the deadlines stipulated in the written
request from CERT.
The lab receives these CERT requests and must request patient records, progress
notes, etc. from the physician’s office and/or clinic. Therefore, it is critical for each
office/clinic to understand that we have time limits to receive this information and must
respond to Medicare within the timeframe given to the laboratory. Upon receipt of
documentation, CERT reviews the claims and medical records from the
providers/suppliers who submitted the claims, reviewing the claims for compliance
with Medicare coverage, coding, and billing rules.
Below are the guidelines from Medicare to assist in documentation and provide
guidance to follow when ordering Laboratory tests.
Documentation Guidelines for Medicare Services
This article is being revised and reprinted from "Medicare B News," Issue 236 dated
April 17, 2007, to ensure that the Noridian Adminstrative Services (NAS) provider and
supplier community has access to recent publications that contain the most current,
accurate and effective information available.
Medical records should be complete, legible, and include the following information:
• Reason for encounter, relevant history, findings, test results, and date of service.
• Assessment and impression of diagnosis.
• Plan of care with date and legible identity of the observer.
• Documentation that supports that the rendering/billing provider indicated on the claim
is the healthcare professional providing the service. (*Note)
• Records should not only substantiate the service performed, but also the required
level of care.
If the physician uses a scribe (an individual taking notes), the scribe needs to fully sign
the note, with their own credentials, followed by the physician’s signature and
credentials.
6
April 2013
Documentation Requests, Medicare Billing
* Note: Medicare needs to identify primary physicians/practitioners of a service not
only for use in standard claims transactions, but also for review, fraud detection, and
planning policies. In order to accomplish this, NAS (Noridian Administration Services)
must be able to determine and verify the rendering physician/practitioner for each
outpatient service billed to Medicare. It is very important that the individual(s)
performing a billed service is/are identified.
By law, Medicare contractors [Medicare Administrative Contractors (MAC) Part B
Carriers and Medicare Administrative Contractors (MAC) Part A Fiscal Intermediaries]
can review any information, including medical records, pertaining to a Medicare claim.
Providers billing Medicare for their services must act in accordance with the following
conditions:
• Document in appropriate office records and/or hospital records each time a covered
Medicare service is provided or ordered. In the case of laboratory test orders, the
exact name of the test(s) being ordered needs to be in the patient's medical record.
When providing concurrent care for hospital or custodial care facility patients,
physicians should identify their specialty in order to help support the necessity. Write
medical information legibly and sign each entry with a legible signature, or ensure that
the provider’s/author’s/observer’s identity is present and legible.
Medical information should be clear, concise, and reflect the patient's condition.
Sign progress notes for hospital and custodial care facility patients with all entries
dated and signed by the healthcare provider who actually examined the patient.
Provide sufficient detail to support diagnostic tests that were furnished and the level of
care billed.
Do not use statements such as “same as above” or ditto marks (“). This is not
acceptable documentation that the service was provided on that date. The “burden of
proof” remains with the provider to substantiate services and/or supplies billed to
Medicare. During the audit process, if documentation is needed, the physician or
supplier must provide the required documentation within the deadlines stipulated in
7
April 2013
Advance Beneficiary Notice, Medicare Billing
The Omnibus Budget Reconciliation Act of 1986 (OBRA)
included a limitation of liability (or waiver of liability) provision
that provided beneficiaries with protection from liability when
they, in good faith, receive services from a Medicare provider
for which Medicare payment is subsequently denied as not
"reasonable and necessary."
Please provide an ICD-9
code for each test
ordered for Medicare
patients.
An Advance Beneficiary Notice (ABN) should be obtained
whenever a provider has reason to believe a procedure could
be denied as not reasonable and necessary. Generally,
services necessitating a signed ABN are those that are
payable in some instances, but not payable in others. These
can include:
Screening Tests
Tests that might be ordered as part of a routine exam (when
the patient does not exhibit evidence of a particular disease)
are not covered.
Experimental ("Investigational") Tests
Tests designated by the manufacturer as "for research or
investigational use," and thus considered experimental or
investigational, are also not covered by Medicare.
Tests Performed Too Frequently
Tests that are performed more frequently
recommended by Medicare are not covered.
than
is
Laboratory tests for which Medicare has established either a
National Coverage Decision (NCD) or for which a Medicare
Administrative Contractor (MAC) has established a Local
Coverage Decision (LCD).
Tests Not Medically Necessary
Tests that are not medically necessary for a diagnosis or
condition - in Medicare's opinion - are not covered.
Laboratory tests that are specifically excluded by the Medicare
program. (e.g., General Health Panels)
8
April 2013
Advance Beneficiary Notice, Medicare Billing
Please provide the laboratory with a valid Advance
Beneficiary Notice when you have reason to believe
Medicare may deny a procedure as 'medically
unnecessary.'
The procedure for obtaining a Medicare waiver (ABN) is based
on the current list of tests for which Medicare requires an
ICD9 code to consider payment. Please refer to the "Current
Lab Services That Require Proof of Medical Necessity" list. Do
not obtain a Medicare waiver (ABN) for every Medicare
patient, but only for those who may be held liable for the
service.
Medicare is very specific about what elements are required on
an ABN for it to be considered valid. Absence of any of the
required elements invalidates that ABN and is the same as no
ABN at all. Medicare is also very specific about format and
appearance of the ABN. Please take a moment to review the
ABN that follows. The following must be completed on each
ABN obtained:
1. Patient Name
2. Date of Birth or other unique identifier as Identification
Number. Must not use Medicare numbers (HICNs) or SSN.
3. Specific tests the patient was advised could be denied must
be listed in the appropriate column.
4. The reason these tests may be denied must be listed in the
appropriate column.
5. The estimated cost of the test(s), to the best of your
knowledge, must be provided in the appropriate column.
6. Once the information is recorded, ask the patient to read, and
then check Option 1, Option 2, and or Option 3. The patient
must do this.
7. Patient must sign the ABN.
8. Patient must date the ABN.
9
April 2013
Advance Beneficiary Notice, Medicare Billing
10
April 2013
The ABN Request Program
Please provide the laboratory with a valid Advance
Beneficiary Notice when you have reason to believe
Medicare may deny a procedure as 'medically
unnecessary.'
CLS provides ABN assistance through our website
www.clslaboratory.com.com. This program will determine if
an ABN is necessary without the need to look through a book
or manual. How to use it:
1. Go to our website and click on ABN Request.
2. Select the entity where the testing will be performed. The Bill
Class field should automatically populate with the appropriate
code for that entity.
3. Enter our workpar (or ?test name, if unknown) for each and
every test the provider has ordered in the first box. Separate
the workpars with a comma or vertical bar leaving no spaces
between characters.
4. Specific tests the patient was advised could be denied must
be listed in the appropriate column.
5. In the second box, enter the ICD-9 codes provided on the
requisition, using the same separators with no spaces
between characters.
6. Click on the Medical Necessity button. The program will
inform you if the test/s require an ABN. If required, an ABN
must be printed out.
7. Enter the patient’s name and date of birth into the appropriate
fields and click on the Generate Printable ABN button. The
ABN will have the patient’s name, date of birth, and the cost of
the testing listed.
8. Print out the ABN and explain it to the patient.
9. Have the patient check Option 1, 2 or 3, and then the patient
must date and sign the form.
11
April 2013
Medicare Secondary Payer
Medicare Secondary Payer (MSP) refers to those instances in
which Medicare does not have the primary responsibility for
paying the medical expenses for a Medicare beneficiary.
All Providers should screen Medicare patients to obtain
correct and current health insurance information before
submitting a primary claim to Medicare.
By completing the MSP Questionnaire to initially screen your
Medicare patients, you will help reduce costs to the Medicare
Program as well as administrative costs to your practice.
Requisitions provided to the laboratory should reflect accurate
patient insurance information, including screening for
Medicare Secondary Payer. Laboratory Patient Service Center
employees will provide Medicare Secondary Payer screening
when performing phlebotomy on Medicare beneficiaries.
Physician offices that are unable to provide Medicare
Secondary Payer screening are encouraged to direct their
patients to our Patient Service Centers for this vital
requirement of the Medicare Program.
References
Medicare Part B 1999 Basic Billing Manual
Medicare B New, Issue 167 "Medicare Secondary Payer"
Hospital Manual-Section 295.1, 301-301.2 January 1999
www.cms.gov/MedicareSecondPayerandYou/
www.noridianmedicare.com/
www.noridianmedicare.com/p-medb/news/faq/msp.html
12
April 2013
Medicare Secondary Payer (MSP) Questionnaire
Medicare Secondary Payor (MSP) Questionnaire (LAB)
Medicare requires the questions below in Part I to be answered by each patient, before Medicare is billed
for medical services. If the answer to any of these questions is "yes," please complete the appropriate
follow-up information in Part II.
Patient Name:
Medicare #:
Date of Service:
Part I
Circle NO or YES
Part II
Date benefits began: ________/______/_________
1. Are you receiving Black Lung
Benefits?
2. Are you receiving any gov't
funded research program that
would pay for this service?
3. Has the Dept of Veteran's
Affairs (DVA) agreed to pay for
these procedures?
4. Is this lab procedure being
done due to a work related
accident/condition?
NO
YES
NO
YES
NO
YES
NO
YES
Date of injury/illness: ________/______/_________
Name/Address of WC plan:
Policy or ID #:
5. Is this lab procedure being
done due to a non-work related
accident?
NO
YES
Date of accident: ________/______/_________
Type of accident: Automobile or Non-Auto?
Name/Address of no-fault or liability insurer?
6. Are you entitled to Medicare
based on: circle field(s) to R
7. AGE: Are you currently
employed?
Which government program and research grant will
pay primary benefits for this lab test(s)?
Insurance claim number: _______________
Was another party responsible for the accident?
Name/address of any liability insurer?
DISABILITY
ESRD (End Stage Renal Dis)
AGE
Proceed only to #7-8 Proceed only to #9-10
Proceed to #11-14
NO
YES
Name/Address of Employer
8. AGE: Is your spouse currently
employed?
9. DISABILITY: Are you currently
employed?
10. DISABILITY: Is a family
member currently employed?
NO
YES
Name/Address of Spouse's Employer
NO
YES
NO
YES
11. ESRD: Do you have group
health plan coverage
NO
YES
Do you have Group Health Plan coverage based on
your own or a spouse's current employment?
Does employer who has GHP employ 20 or more?
Name/Address of GHP
Policy ID Number
Group ID Number
Name of Policy Holder
Relationship to patient
12. ESRD: Have you received a
kidney transplant?
13. ESRD: Have you received
maintenance dialysis treatment?
NO
YES
Date of transplant: ________/______/_________
NO
YES
Date dialysis began: ________/______/_________
14. ESRD: Are you within the 30
month coordination period?
NO
YES
13
April 2013
United Healthcare
(UHC)
Billing
14
April 2013
Hepatitis Screening Limitations, United Healthcare (UHC)
UHC has implemented a Hepatitis Screening testing policy and has greatly reduced the
number of ICD9 codes that they will now cover. This is effective April 1, 2012.
It is the provider’s responsibility to select diagnosis codes carried out to the highest level
of specificity and selected from the ICD-9-CM code book appropriate to the year in which
the service is rendered for the claim(s) submitted.
UHC's Hepatitis Screening policy should be retained as a reference, but remember that
every code provided on the lab order must be substantiated in the patient’s chart.
United’s policy can be reviewed in its entirety at:
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/enUS/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Polici
es%20and%20Protocols/Medical%20Policies/Medical%20Policies/Hepatitis_Screening.p
df
A list of UHC approved codes for Hepatis Screening testing is provided below.
UHC SUMMARY OF "PROVEN" DX CODES FOR HEPATITIS SCREENING TESTING:
APPLICABLE CODES: "The codes listed in this policy are for reference purposes only.
Listing of a service or device code in this policy does not imply that the service described
by this code is a covered or non-covered health service. Coverage is determined by the
benefit document. This list of codes may not be all inclusive."
CPT 86704 Hepatitis B core antibody (HBcAB); total
CPT 86705 Hepatitis B core antibody (HBcAB); IgM antibody
CPT 86706 Hepatitis B surface antibody (HBsAB)
CPT 86707 Hepatitis Be antibody (HBeAB)
CPT 86708 Hepatitis A antibody (HAAb); total
CPT 86709 Hepatitis A antibody (HAAb); IgM antibody
CPT 86803 Hepatitis C antibody
CPT 86804 Hepatitis C antibody; confirmatory test (eg, immunoblot)
CPT 87340 Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple step method; hepatitis B surface antigen (HBsAG)
CPT 87341 Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple step method; hepatitis B surface antigen (HBsAG)
neutralization
CPT 87350 Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple step method; hepatitis Be antigen (HBeAG)
15
April 2013
Hepatitis Screening Limitations, United Healthcare (UHC)
Proven
Description
Diagnosis Code
042
054.10-054.19
070.0-070.9
078.10
078.11
078.19
079.4
Human immunodeficiency virus [HIV] disease
Herpes zoster with other nervous system complications
Viral hepatitis
Viral warts, unspecified
Condyloma acuminatum
Other specified viral warts
Human papillomavirus in conditions classified elsewhere and of unspecified site
090.0-090.9
091.0-091.9
092.0
092.9
093.0-093.9
094.0-094.9
095.0-095.9
096
097.0
097.1
097.9
098.0-098.89
099.0-099.9
131.00-131.9
135
286.0-286.4,
286.6-286.9
304.00-304.93
456.0
456.1
555.0-555.9
556.0-556.5,
556.8, 556.9
571.0
571.1
571.2
571.3
571.5
571.6
571.8
Congenital syphilis
Early syphilis, symptomatic
Early syphilis, latent, serological relapse after treatment
Early syphilis, latent, unspecified
Cardiovascular syphilis
Neurosyphilis
Other specified forms of late symptomatic syphilis
Late syphilis, latent
Late syphilis, unspecified
Latent syphilis, unspecified
Syphilis, unspecified
Gonococcal infections
Other venereal disease
Trichomoniasis
Sarcoidosis
Coagulation defects
Drug dependence
Esophageal varices with bleeding
Esophageal varices without mention of bleeding
Regional enteritis
Ulcerative colitis
Alcoholic fatty liver
Acute alcoholic hepatitis
Alcoholic cirrhosis of liver
Unspecified alcoholic liver damage
Cirrhosis of liver without mention of alcohol
Biliary cirrhosis
Other chronic nonalcoholic liver disease
16
April 2013
Hepatitis Screening Limitations, United Healthcare (UHC)
571.9
585.3
585.4
585.5
585.6
608.4
614.9
616.10
616.11
631
632
633.00-633.91
634.00-634.92
635.00-635.92
636.00-636.92
637.00-637.92
638.0-638.9
639.0-639.9
640.00-640.93
641.00-641.93
642.00-642.94
643.00-643.93
644.00-644.21
645.10-645.23
646.00-646.93
647.00-647.94
648.00-648.94
649.00-649.73
650
651.00-651.93
652.00-652.93
653.00-653.93
654.00-654.94
655.00-655.93
656.00-656.93
657.00-657.03
658.00-658.93
Unspecified chronic liver disease without mention of alcohol
Chronic kidney disease, Stage III (moderate)
Chronic kidney disease, Stage IV (severe)
Chronic kidney disease, Stage V
End stage renal disease
Other inflammatory disorder of male genital organs
Unspecified inflammatory disease of female pelvic organs and tissues
Vaginitis and vulvovaginitis, unspecified
Vaginitis and vulvovaginitis in diseases classified elsewhere
Other abnormal product of conception
Missed abortion
Ectopic pregnancy
Spontaneous abortion
Legally induced abortion
Illegally induced abortion
Unspecified abortion
Failed attempted abortion
Complications following abortion and ectopic and molar pregnancies
Hemorrhage in early pregnancy
Antepartum hemorrhage, abruptio placentae and placenta previa
Hypertension complicating pregnancy, childbirth and the puerperium
Excessive vomiting in pregnancy
Early or threatened labor
Late pregnancy
Other complications of pregnancy, not elsewhere classified
Infectious and parasitic conditions in the mother classifiable elsewhere, but
complicating pregnancy, childbirth or the puerperium
Other current conditions in the mother classifiable elsewhere, but complicating
pregnancy, childbirth or the puerperium
Other conditions or status of the mother classifiable elsewhere, but
complicating pregnancy, childbirth or the puerperium
Normal delivery
Multiple gestation
Malposition and malpresentation of fetus
Disproportion
Abnormality of organs and soft tissues of pelvis
Known or suspected fetal abnormality affecting management of mother
Other known or suspected fetal and placental problems affecting management
of mother
Polyhydramnios
Other problems associated with amniotic cavity and membranes
17
April 2013
Hepatitis Screening Limitations, United Healthcare (UHC)
659.00-659.93
669.00-669.94
670.00-670.84
672.00-672.04
673.00-673.84
674.00-674.04
674.80-674.94
Other indications for care or intervention related to labor and delivery, not
elsewhere classified
Obstructed labor
Abnormality of forces of labor
Long labor
Umbilical cord complications
Trauma to perineum and vulva during delivery
Other obstetrical trauma
Postpartum hemorrhage
Retained placenta or membranes, without hemorrhage
Complications of the administration of anesthetic or other sedation in labor and
delivery
Other complications of labor and delivery, not elsewhere classified
Major puerperal infection
Pyrexia of unknown origin during the puerperium
Obstetrical pulmonary embolism
Cerebrovascular disorders in the puerperium
Other and unspecified complications of puerperium, not elsewhere classified
696.0
696.1
714.0
714.1
714.2
714.81
714.89
714.9
720.0
720.9
790.4
794.8
959.14
996.82
V01.6
V01.79
V02.60-V02.69
V02.7
V02.8
V08
V22.0-V22.2
V23.0-V23.3
Psoriatic arthropathy
Other psoriasis and similar disorders
Rheumatoid arthritis
Felty's syndrome
Other rheumatoid arthritis with visceral or systemic involvement
Rheumatoid lung
Other specified inflammatory polyarthropathies:other
Unspecified inflammatory polyarthropathy
Ankylosing spondylitis
Unspecified inflammatory spondylopathy
Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase
Nonspecific abnormal results of function study of liver
Other injury of external genitals
Complications of transplanted liver
Contact with or exposure to venereal diseases
Contact with or exposure to other viral diseases
Viral hepatitis carrier
Carrier or suspected carrier of gonorrhea
Carrier or suspected carrier of other venereal diseases
Asymptomatic human immunodeficiency virus [HIV] infection status
Normal pregnancy
Supervision of high-risk pregnancy
660.00-660.93
661.00-661.93
662.00-662.33
663.00-663.93
664.00-664.94
665.00-665.94
666.00-666.34
667.00-667.14
668.00-668.94
18
April 2013
Hepatitis Screening Limitations, United Healthcare (UHC)
V23.41
V23.49
V23.5
V23.7
V23.81-V23.86,
V23.89
V23.9
V24.0-V24.2
V26.29
V28.2
V28.81-V28.89
V28.9
V42.0-V42.9
V45.11
V56.0
V56.8
V58.11
V58.2
V59.01-V59.6,
V59.8-V59.9
V69.2
V71.5
V72.42
V74.5
V83.01-V83.02
V87.41
V87.46
V91.00 -V91.99
Supervision of pregnancy with history of pre-term labor
Supervision of pregnancy with other poor obstetric history
Pregnancy with other poor reproductive history
Insufficient prenatal care
Supervision of high-risk pregnancy
Unspecified high-risk pregnancy
Postpartum care and examination
Other investigation and testing
Other antenatal screening based on amniocentesis
Other specified antenatal screening
Unspecified antenatal screening
Organ or tissue replaced by transplant
Renal dialysis status
Encounter for extracorporeal dialysis
Encounter other dialysis
Encounter for antineoplastic chemotherapy
Blood transfusion, without reported diagnosis
Donors of other or unspecified organ or tissue
High-risk sexual behavior
Observation following alleged rape or seduction
Pregnancy examination or test, positive result
Screening examination for venereal disease
Hemophilia A carrier
Personal history of antineoplastic chemotherapy
Personal history of immunosuppressive therapy
Multiple gestation placenta status
19
April 2013
Medicare Coverage
Limitation Resources
20
April 2013
NATIONAL COVERAGE DECISION AND LOCAL COVERAGE DECISION TEST LIST AND PRICES
Workpar
AFP
Multiple
B12
BTNP
CA125
CA15-3
CA19-9
CA27.29
CARFTR
CBC
CEA
Multiple
CHO
UA.ID
CURNNS
DIF
DIG
DLDL
FERR
FOLATE
FREE T4
FRUCTO
Multiple
GGT
Description
Alpha Feto-protein
Assay of NOS vitamin
B12 Assay
B-Type Natriuretic
Peptide
CA125
CA15-3
CA19-9
CA27-29
Carnitine, Free and Total
CBC (All complete Blood
Counts)
CEA
Cell Function Assay w/
Stim
Cholesterol
Culture, Organism ID
Culture Urine Colony
Count
Differential (Blood
Counts), Manual
Digoxin
Direct LDL
Ferritin
Folate
Free T4
Fructosamine
Flow Cytometry
CPT4
82105 (NCD)
84591 (LCD)
82607 (LCD)
83880 (LCD)
Eff Date
11/25/2002
8/13/2012
8/13/2012
8/13/2012
Est Fee
$
60.00
Client Services
$
46.00
$
153.00
86304 (NCD)
86300 (NCD)
86301 (NCD)
86300 (NCD)
82379 (LCD)
11/25/2002
11/25/2002
11/25/2002
11/25/2002
8/13/2012
$
$
$
$
$
62.00
85.00
75.00
66.00
151.00
85021-85028
(NCD)
82378 (NCD)
86352 (LCD)
11/25/2002
$
44.00
11/25/2002
8/13/2012
$
54.00
Client Services
82465 (NCD)
87088 (NCD)
87086 (NCD)
11/25/2002
11/25/2002
11/25/2002
$
$
$
11.00
81.00
58.00
85007-85008
(NCD)
80162 (NCD)
83721 (NCD)
82728 (NCD)
82746 (LCD)
84439 (NCD)
82985 (NCD)
88182, 88184,
88185, 88187,
88188, 88189
(LCD)
82977 (NCD)
11/25/2002
$
62.00
11/25/2002
11/25/2002
11/25/2002
8/13/2012
11/25/2002
11/25/2002
8/13/2012
$
47.00
$
58.00
$
46.00
$
47.00
$
44.00
$
53.00
Client Services
11/25/2002
$
11.00
11/25/2002
$
11.00
11/25/2002
11/25/2002
$
$
45.00
52.00
11/25/2002
11/25/2002
$
$
41.00
42.00
11/25/2002
11/25/2002
$
$
42.00
42.00
11/25/2002
8/13/2012
11/25/2002
$
$
$
138.00
46.00
55.00
11/25/2002
$
355.00
GLU
Gamma
Glutamyltransferase
Glucose
GLHGB
HCG-QUANT
Glycohemoglobin
HCG Quantitative
HDL
HCT
HGB
AUT
HDL
Hematocrit (Including
Spun)
Hemoglobin
Hemogram, Automated
HEPACU
HCRP
12HIVR
Hepatitis Panel, Acute
High Sensitivity CRP
HIV (Virology Serology)
HIVQBD
HIV-1 Ultrasensitive RNA 87536 (NCD)
82947-82948,
82962 (NCD)
83036 (NCD)
84702 / 84703
(NCD)
83718 (NCD)
85013-85014
(NCD)
85018 (NCD)
85021, 85027
(NCD)
80074 (NCD)
86141 (LCD)
86703 (NCD)
21
April 2013
NATIONAL COVERAGE DECISION AND LOCAL COVERAGE DECISION TEST LIST AND PRICES
Workpar
HIVUS
HIV2AB
1HIVWB
Multiple
Multiple
Multiple
HOMCY
HYPOA
IRON.BIND
IRN
LIPID
PLACA2
LAMA
B.NTX
OC.BLD
PTT
PLT
PT
PSA
Multiple
T3UP
T4
BTB
TRANSFERRIN
TRIG
TSH
VIA
VTB1B
VTB6P
VB2
VIT.C
VDOH
VITD23
Description
HIV-1, Ultrasensitive
Quant by PCR
HIV-2 Antibody, Elisa
HIV-1 Western Blot
HIV-2, Amplified Probe
HIV-2, Direct Probe
HIV-2, Quant
Homocysteine
Hypothyroid Profile
Iron Binding Capacity
Iron, Total
Lipid Profile
Lipoprotein PLA2
Lymphocyte AG &
Mitogen Prolif PNL
N-Telopeptides (NTX)
Occult Blood
Partial Thromboplastin
Time
Platelet Count
Prothrombin Time
PSA
Qualitative Drug
Screening
T3 Uptake
T4 by Icma
Thyroid Profile
Eff Date
11/25/2002
Est Fee
$
86702 (NCD)
86689 (NCD)
87538 (NCD)
87538 (NCD)
87539 (NCD)
83090 (LCD)
84479,84436,
84443 (NCD)
83550 (NCD)
83540 (NCD)
80061 (NCD)
83698 (LCD)
86353 (LCD)
11/25/2002
11/25/2002
11/25/2002
11/25/2002
11/25/2002
8/13/2012
11/25/2002
$
389.00
$
245.00
Client Services
Client Services
Client Services
$
84.00
$
133.00
11/25/2002
11/25/2002
11/25/2002
8/13/2012
8/13/2012
$
$
$
$
$
40.00
40.00
44.00
134.00
1,862.00
82523 (NCD)
82270 (NCD)
85730 (NCD)
11/25/2002
11/25/2002
11/25/2002
$
$
$
116.00
55.00
41.00
11/25/2002
11/25/2002
11/25/2002
8/13/2012
$
42.00
$
41.00
$
54.00
Client Services
11/25/2002
11/25/2002
11/25/2002
$
$
$
45.00
44.00
89.00
11/25/2002
11/25/2002
11/25/2002
8/13/2012
8/13/2012
$
$
$
$
$
62.00
11.00
45.00
101.00
128.00
84207 (LCD)
84252 (LCD)
82180 (LCD)
82306 (LCD)
82306 (LCD)
8/13/2012
8/13/2012
8/13/2012
8/13/2012
8/13/2012
$
$
$
$
$
115.00
180.00
151.00
88.00
186.00
82652 (LCD)
8/13/2012
$
128.00
84446 (LCD)
84597 (LCD)
85048 (NCD)
8/13/2012
8/13/2012
11/25/2002
$
$
$
114.00
256.00
42.00
85595 (NCD)
85610 (NCD)
84153 (NCD)
80102, G0431,
G0434 (LCD)
84479 (NCD)
84436 (NCD)
84479, 84436
(NCD)
Transferrin
84466 (NCD)
Triglycerides
84478 (NCD)
TSH
84443 (NCD)
Vitamin A
84590 (LCD)
Vitamin B-1, whole blood 84425 (LCD)
VIE
VITK1
WBC
Vitamin B-6
Vitamin B2, Riboflavin
Vitamin C, Plasma
Vitam D, 25-Hydroxy
Vitamin D2/D3, 25Hydroxy
Vitamin D (1, 25DiHydroxy
Vitamin E
Vitamin K1
White Cell Count
Reviewed:
April 2013
VIDD
CPT4
87536 (NCD)
22
372.00
April 2013
INVESTIGATIONAL TEST LIST AND PRICES: REQUIRE ABN EVERY TIME THEY ARE ORDERED
Workpar
21HYAB
CPT4
83519
Eff Date
Investigational
Est Fee
$
216.00
82172
Never Covered
$
115.00
84588
Investigational
$
149.00
83520
86160
Investigational
Investigational
$
$
621.00
187.00
86160
86160
Investigational
Investigational
$
$
297.00
356.00
86160
Investigational
$
364.00
86625
Investigational
$
435.00
86352
Never Covered
Client Services
CHROMA
Chromogranin A
CYSTICERCUS.AB Cysticercus AB
86316
86682
Investigational
Investigational
$
$
178.00
209.00
DENGUE
86790 x 2
Investigational
$
197.00
86305
Never Covered
$
634.00
86668
Investigational
$
143.00
86668
Investigational
$
147.00
86668 x2
Investigational
$
227.00
82530
83516 x 4
83516 x 2
Investigational
Investigational
Investigational
$
$
$
374.00
620.00
254.00
83516
Investigational
$
410.00
86692
Investigational
$
193.00
83088
83088
83088
86689
83520
82172
Investigational
Investigational
Investigational
Investigational
Investigational
Never Covered
$
$
$
$
$
$
153.00
153.00
153.00
292.00
388.00
62.00
83520
85549
83873
Investigational
Investigational
Investigational
$
$
$
322.00
111.00
135.00
APOLA, APOLB
ADH
ADIPA
C2
C3AL
C7SP
C9CSP
CAMPAB
multiple
EPIP4A
FTABGA
FTABMA
FTAGMA
FCORTS
GM1.AB
GM1ABS
GM1COM
HEPDAB
HIST
HISTP
HIST-U
HIV2WB
INHB
LPA.MAYO
LEPTNA
MUR
MBP
Description
21 Hydroxylase
Antibodies
Apolipoprotein A & B
Arginine Vasopressing
Hormone
Adiponectin
C2 Complement
Component
C3AL
Complement Component
C7
Complement Component
C9
Campylobacter Jejuni
Antibody
Cellular Function Assay
Involving Stimulation
Dengue Fever Virus AB,
IGG & IGM
Human Epididymis
Protein
Francisella Tularensis AB
Igg
Francisella Tularensis AB
Igm
Francisella Tularensis
ABS Igg & Igm
Cortisol, Serum Free
GM 1 Anitbody Panel
Ganglioside (GM1) ABS,
IGG & IGM
Ganglioside Asialo GM1
GM2
Hepatitis D Virus
Antibody, Total EIA
Histamine
Histamine, Plasma
Histamine, Urine
HIV-2 Antibody, IB
Inhibin B
Lipoprotein (A)
Lysozyme
Myelin Basic Protein
Maternal Screen,
Integrated Spec #1
23
April 2013
INVESTIGATIONAL TEST LIST AND PRICES: REQUIRE ABN EVERY TIME THEY ARE ORDERED
Workpar
MSSIS2
MSSS2
MYAJO1
NEUIGG
NMRLP
NMR630
NSECA
NSEN
PCALTA
PHOSPHO
T3REV
TRYPTS
B.VAPCT1
B.ASAWK1
VEGF
VGCCAB
Reviewed:
Description
Maternal Screen,
Sequential Spec #2
Maternal Screen,
Sequential Spec #2
Phospholipids, serum or
Plasma
Neuronal Antibodies Igg
by
NMR Lipoprofile
CPT4
82105, 84702,
82677, 86336
82105, 84702,
82677, 86336
83516 x 7, 86235
x3
83516
Eff Date
Investigational
Est Fee
$
475.00
Investigational
$
475.00
Investigational
$
404.00
Investigational
$
557.00
83704
Never Covered
$
159.00
83704
Never Covered
$
138.00
86316
Investigational
$
161.00
86316
Investigational
$
171.00
84145
Never Covered
$
633.00
T-3 Reverse
Vascular Endothelial
Growth Factor
Tryptase
Lipo, Frac
84311
84482
Investigational
Investigational
$
$
147.00
138.00
83520
83701
Investigational
Never Covered
$
$
478.00
92.00
Thromboxane
Metabolites
Vascular Endothelial
Growth Factor
Voltage Gated Calcium
Chanel Ab
84431
Never Covered
$
717.00
83520
Investigational
$
897.00
83519
Investigational
$
969.00
NMR Lipoprofile Test
(LDL-P Only)
Neuron Specific Enolase,
CSF
Plasminogen Act Inhib-1,
4G/5G
Procalcitonin
April 2013
24
April 2013
FREQUENCY TEST LIST: IF ANY OF THESE TEST(S) ARE REQUIRED TO BE RUN MORE OFTEN
THAN THE ALLOWABLE FREQUENCIES LISTED, THEY MUST BE DIAGNOSTIC OR HAVE AN ABN
FOR FREQUENCY.
Description
CPT4
Glycated Hemoglobin 83036
Frequency Covered
1 every 3 months
Covered Diagnosis
See NCD detail
Glucose
82947
1 per year
V77.1 Special screening for endocrine,
nutritional, metabolic, and immunity
disorders; diabetes mellitus
Occult Blood (Fecal)
82270, 82274
1 per year
V76.51 Special screening for malignant
neoplasms of colon
1 every 2 years
V76.2 Special screening for malignant
neoplasms of the cervix
V15.89 Other specified personal history
presenting hazards to health
V76.47 Special Screening for malignant
neoplasms of the vagina
Pap Smear
PSA
84153
1 per year for men
over 50 years of age
V76.44 Special screening for malignant
neoplasms of prostate
LIPID
80061
1 every 5 years
V81.0 Special screening for ischemic
heart disease
V81.1 Special screening for
hypertension
V81.2 Special screening for other &
unspecified cardiovascular conditions
***LIPID PANEL FREQUENCY LIMITATION*** NCD 190.23 Summary for Lipid Testing
Routine screening is generally not covered by Medicare
Borderline high total or LDL cholesterol levels: Lipid panel is reasonable on an
annual basis.
First year of anti-lipid dietary or pharmacologic therapy.
* One component of the panel or a measured LDL may be reasonable up to 6
times the first year.
* When documentation supports marked elevations or changes in anti-lipid
therapy due to inadequate initial patient response to dietary or pharmacologic
therapy, more frequent total cholesterol, HDL cholesterol, LDL cholesterol and
triglyceride testing may be indicated.
* After treatment goals are established: LDL cholesterol or total cholesterol may
be measured three times yearly.
Long-term anti-lipid dietary or pharmacologic therapy: Lipid panel is reasonable
on an annual basis.
If no dietary or pharmacologic therapy is advised, monitoring is not necessary.
When evaluating non-specific chronic abnormalities of the liver, lipid panel would
generally not be indicated more than twice per year.
25
April 2013
FREQUENCY TEST LIST: IF ANY OF THESE TEST(S) ARE REQUIRED TO BE RUN MORE OFTEN
THAN THE ALLOWABLE FREQUENCIES LISTED, THEY MUST BE DIAGNOSTIC OR HAVE AN ABN
FOR FREQUENCY.
Description
CPT4
LCD Frequency
Covered (Per
Beneficiary, Per
Provider)
Acceptable Reasons (Diagnosis Codes) for
Exceeding the LCD Maximum
Lipids
80061
82465
83718
83721
84478
84436
84439
84443
84479
No more than every 2
months for any test
whether in a panel or
separately ordered
V58.69 Inability to stabilize lipid-lowering drug
dosing.
V58.69 Adverse reaction to lipid-lowering drug.
577.0-577.1 Pancreatitis.
4 times per year for
most persons, except
for selected
endocrine
presentations
82948
82962
1 per month
Inability to stabilize thyroid medication dosing.
Thyrotoxicosis.
Concurrent endocrinopathies.
Hypothyroidism.
Codes pertaining to above line items : 226,
242.00-242.91, 243, 244.0-244.3, 244.8-244.9,
245.0-245.4, 245.8-245.9, 250.00-250.03,
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, 250.90-250.93,
252.1, 253.2, 253.4, 255.2, 255.4, 272.0,
272.2, 275.40–275.42, 275.49, 276.0–276.1,
279.4, 281.0, 281.9, 285.9, 290.0,
290.10–290.13, 290.20–290.21, 290.3,
293.0–293.1, 296.00–296.06, 296.10–296.16,
296.20–296.26, 296.30–296.36,
296.40–296.46, 296.50–296.56,
296.60–296.66, 296.7, 296.80–296.82, 296.89,
296.90, 296.99, 300.00–300.02, 300.09, 311,
359.5, 374.41, 374.82, 376.21–376.22, 427.0,
427.31, 428.0, 511.9, 560.1, 625.3, 750.15,
780.02, 780.09, 783.1, 783.21, 784.1,
785.0–785.1, 794.5, V58.69
250.02-250.03, 250.92-250.93 Uncontrolled
diabetes mellitus.
Thyroid Testing
Glucose Testing
***Sources of Information and Basis for Decision Novitas Solutions, Inc. JH Local Coverage
Determination (LCD) Consolidation, L26817 Frequency of Laboratory Tests, TrailBlazer (CO, NM, OK,
TX-A/B).
26
April 2013
Non-covered ICD-9-CM Codes for All NCD Edits, Medicare Billing
Per Medicare: 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.
The individual ICD-9-CM codes included in code ranges in the table below can be viewed
on CMS’ website under Downloads: Lab Code List. The link is:
http://www.cms.hhs.gov/CoverageGenInfo
Non-covered ICD-9-CM Codes for All NCD Edits:
Code
Description
798.0-798.9
Sudden death, cause unknown
V15.85
V16.1
Personal history of contact with and (suspected) exposure to potentially
hazardous body fluids
Family history of malignant neoplasm, trachea, bronchus, and lung
V16.2
Family history of malignant neoplasm, other respiratory and
V16.40
Family history of malignant neoplasm, genital organs
V16.50
Family history of malignant neoplasm, urinary organs
V16.51
Family history of malignant neoplasm, kidney
V16.52
Family history of malignant neoplasm, bladder
V16.59
Family history of malignant neoplasm, other
V16.6
Family history of malignant neoplasm, leukemia
V16.7
Family history of malignant neoplasm, other lymphatic and
V16.8
Family history of malignant neoplasm, other specified malignant
V16.9
Family history of malignant neoplasm, unspecified malignant
V17.0-V17.3
Family history of certain chronic disabling diseases
V17.41
Family history of sudden cardiac death (SCD)
V17.49
Family history of other cardiovascular diseases
V17.5-V17.89
V18.0
Family history of asthma; other chronic respiratory conditions
arthritis;other musculoskeletal diseases
Family history of diabetes mellitus
V18.11
Family history of multiple endocrine neoplasia (MEN) syndrome
V18.19
Family history of other endocrine and metabolic diseases
V18.2-V18.4, V18.51,
V18.59,V18.61, V18.69,
V18.7-V18.9
Family history of anemia; other blood disorders; mental retardation;
colonic polyps; other digestive disorders; polycystic kidney; other
kidney diseases; other genitourinary diseases; infectious and parasitic
diseases; genetic disease carrier
Family history of other conditions
V19.0-V19.8
V20.0-V20.2
Health supervision of infant or child
V20.31
Health supervision for newborn under 8 days old
27
April 2013
V20.32
Health supervision for newborn 8 to 28 days old
V28.0-V28.9
Encounter for antenatal screening of mother
V50.0-V50.9
Elective surgery for purposes other than remedying health states
V53.2
Hearing aid
V60.0-V60.6
V60.81
Lack of housing; inadequate housing; lack of material resources;
person living alone; no other household person able to render care;
holiday relief care; and person living in residential institution
Foster care (status)
V60.89
Other specified housing or economic circumstances
V60.9
Unspecified housing or economic circumstances
V62.0
Unemployment
V62.1
Adverse effects of work environment
V65.0
Healthy persons accompanying sick persons
V65.11
Pediatric pre-birth visit for expectant parent(s)
V65.19
Other person consulting on behalf of another person
V68.0-V68.9
Encounters for administrative purposes
V70.0-V70.9
General medical examinations
V73.0-V73.6
Special screening examinations for viral and chlamydia diseases
V73.81
Special screening examinations for Human papillomavirus (HPV)
V73.88-V73.89
Other specified chlamydial and viral diseases
V73.98-V73.99
Unspecified chlamydial and viral disease
V74.0-V74.9
Special screening examinations for bacterial and spirochetal diseases
V75.0-V75.9
Special screening examination for other infectious diseases
V76.0
Special screening for malignant neoplasms, respiratory organs
V76.3
Special screening for malignant neoplasms, bladder
V76.42-V76.43, V76.45V76.47, V76.49, V76.50,
V76.52, V76.81, V76.89,
V76.9
V77.0
Special screening for malignant neoplasms,(sites other than breast,
cervix, and rectum)
V77.2-V77.99
Special screening for endocrine, nutrition, metabolic, and immunity
V78.0-V78.9
Special screening for disorders of blood and blood-forming organs
V79.0-V79.9
Special screening for mental disorders
V80.01
Special screening for traumatic brain injury
V80.09
Special screening for other neurological conditions
V80.1-V80.3
Special screening for glaucoma and other eye conditions; ear
V81.3-V81.6
Special screening for cardiovascular, respiratory, and genitourinary
diseases
Special screening for other conditions
V82.0-V82.6, V82.71,
V82.79, V82.81, V82.89,
V82.9
Special screening for endocrine, nutrition, metabolic, and immunity
28
April 2013
NCD & LCD WASHINGTON B
2013
NCD & LCD
Colorado
Medicare A
29
April 2013
NCD & LCD COLORADO A
Alpha Fetoprotein; Serum Assays for Vitamin and Metabolic Function
Blood Counts B-Type Natriuretic Peptide (BNP) CA125 CA 15-3/CA 27.29 CA 19-9 CEA Circulating Tumor Cell Assay
Collagen Cross Links (NTX) Digoxin Therapeutic Drug Assay(Any Source) Flow Cytometry
Gamma Glutamyltransferase (GGT) Glycated Hemoglobin & Glycated Protein Glucose Testing (Blood) HCG Quantitative Hepatitis Panel, Acute Human Immunodeficiency Virus (HIV)
Viral Load Diagnosis Human Immunodeficiency Virus (HIV) Prognosis Iron Studies, Serum Lipid Profile & Cholesterol Testing Occult Blood, Feces Screening Prostate Specific Antigen (PSA) Prothrombin Time (PT) Partial Thromboplastin Time (PTT) Qualitative Drug Screening
Thyroid Testing Urine Culture 30
NCD
LCD
NCD
LCD
NCD
NCD
NCD
NCD
LCD
NCD
NCD
LCD
NCD
NCD
NCD
NCD
NCD
Page
31-32
33-35
36-40
41
42
43
44
45
46
47
48-50
51-55
56-59
60-61
62-65
66
67
NCD
NCD
NCD
NCD
NCD
NCD
NCD
NCD
LCD
NCD
NCD
68-71
72
73-76
77-79
80-82
83
84-91
92-97
98-99
100-103
104-105
April 2013
ALPHA FETO PROTEIN; SERUM
National Coverage Decision November 25, 2002
CPT: 82105
Alpha Fetoprotein; serum
070.22-070.23
Chronic viral hepatitis B with hepatic coma, with or without mention of
hepatitis delta
Chronic viral Hep B w/out mention of hepatic coma, with or w/out mention of
hepatitis delta
Chronic hepatitis C with hepatic coma
Chronic hepatitis C without mention of hepatic coma
Syphilis of liver
Clonorchiasis
Fascioliasis
Malignant neoplasm of the liver and intrahepatic bile ducts
Malignant neoplasm of the mediastinum
Malignant neoplasm, ovary
Malignant neoplasm of undescended testis
Malignant neoplasm, other and unspecific testis
Secondary malignant neoplasm of mediastinum
Secondary malignant neoplasm of liver
Secondary malignant neoplasm of ovary
Secondary malignant neoplasm, genital organs
Malignant carcinoid tumors of other and unspecified sites
Secondary neuroendocrine tumor, unspecified site
Secondary neuroendocrine tumor of distant lymph nodes
Secondary neuroendocrine tumor of liver
Secondary neuroendocrine tumor of bone
Secondary neuroendocrine tumor of peritoneum
Secondary Merkel cell carcinoma
Secondary neuroendocrine tumor of other sites
Benign neoplasm of liver and biliary passages
Neoplasm of uncertain behavior of liver and biliary passages
Mixed hyperlipidemia
Alpha 1 antitrypsin deficiency
Hereditary hemochromatosis
Hemochromatosis due to repeated red blood cell transfusions
Other hemochromatosis
Other disorders of iron metabolism
Disorder of copper metabolism
Cystic Fibrosis without mention of meconium ileus
Cystic Fibrosis with gastrointestinal manifestations
Other deficiencies of circulating enzymes
Sideroblastic Anemia
Neoplasm related pain (acute) (chronic)
Coronary atherosclerosis due to calcified coronary lesion
Saddle embolus of abdominal aorta
Other arterial embolism and thrombosis of abdominal aorta
Alcoholic cirrhosis of liver
070.32-070.33
070.44
070.54
095.3
121.1
121.3
155.0-155.2
164.2-164.9
183.0
186.0
186.9
197.1
197.7
198.6
198.82
209.20-209.29
209.70
209.71
209.72
209.73
209.74
209.75
209.79
211.5
235.3
272.2
273.4
275.01
275.02
275.03
275.09
275.1
277.00
277.03
277.6
285.0
338.3
414.4
444.01
444.09
571.2
31
AFP (NCD)
ALPHA FETO PROTEIN; SERUM
National Coverage Decision November 25, 2002
571.40
571.41
571.42
571.49
571.5
573.5
608.89
793.11
793.19
793.1
793.2
793.3
793.6
795.89
V10.07
V10.43
V10.47
V86.0-V86.1
Chronic hepatitis, unspecified
Chronic persistent hepatitis
Autoimmune hepatitis
Other chronic hepatitis
Cirrhosis of liver without mention of alcohol
Hepatopulmonary syndrome
Other specified disorders of male genital organs
Solitary pulmonary nodule
Other nonspecific abnormal finding of lung field
Non-specific abnormal findings of lung field
Non-specific abnormal findings of other intrathoracic organs
Non-specific abnormal findings of biliary tract
Non-specific abnormal findings of abdominal area, including retro peritoneum
Other abnormal tumor markers
Personal history of malignant neoplasm, liver
Personal history of malignant neoplasm, ovary
Personal history of malignant neoplasm, testis
Estrogen receptor positive status [ER+]
Reviewed:
April 2013
32
AFP (NCD)
ASSAYS for VITAMIN and METABOLIC FUNCTION
Medicare A Medical Policy August 13, 2012
CPT: 82180
CPT: 82306
CPT: 82379
CPT: 82607
CPT: 82652
CPT: 82746
CPT: 83090
CPT: 83698
CPT: 84207
CPT: 84252
CPT: 84425
CPT: 84446
CPT: 84590
CPT: 84591
CPT: 84597
CPT: 85385
CPT: 86141
CPT: 86352
CPT: 86353
Assay of ascorbic acid
Vitamin D 25 hydroxy
Assay of carnitine
Vitamin B-12
Vit D 1 25-dihydroxy
Assay of folic acid serum
Assay of homocystine
Assay of lipoprotein PLA2
Assay of vitamin B-6
Assay of vitamin B-2
Assay of vitamin B-1
Assay of vitamin E
Assay of vitamin A
Assay of NOS vitamin
Assay of vitamin K
Fibronogen antigen
C-Reactive protein HS
Cell function assay w/ stim
Lymphocyte transformation
The following ICD-9 CM codes support the medical necessity of CPT code 82306 & 82652
252.00 - 252.02
Hyperparathyroidism, unspecified - secondary hyperparathyroidism, nonrenal
252.08
Other hyperparathyroidism
252.1
Hypoparathyroidism
268.0
Rickets active
268.2
Osteomalacia unspecified
268.9
Unspecified vitamin d deficiency
275.3
Disorders of phosphorus metabolism
275.41 - 275.42
Hypocalcemia - hypercalcemia
585.3 - 585.6
Chronic kidney disease, stage iii (moderate) - end stage renal disease
588.81
Secondary hyperparathyroidism (of renal origin)
733.00 - 733.03
Osteoporosis unspecified - disuse osteoporosis
733.09
Other osteoporosis
733.90
Disorder of bone and cartilage unspecified
The following ICD-9 CM codes support the medical necessity of CPT code 82379
277.81 - 277.84
Primary carnitine deficiency - other secondary carnitine deficiency
285.21
Anemia in chronic kidney disease
458.21
Hypotension of hemodialysis
The following ICD-9 CM codes support the medical necessity of CPT code 82607, 82746, 83090
040.2
261
Whipple's disease
Nutritional marasmus
33
ASSAYS for VITAMIN and
METABOLIC FUNCTION (LCD)
ASSAYS for VITAMIN and METABOLIC FUNCTION
Medicare A Medical Policy August 13, 2012
262
263.0
263.2
263.8 - 263.9
266.2
270.4
281.0 - 281.3
Other severe protein-calorie malnutrition
Malnutrition of moderate degree
Arrested development following protein-calorie malnutrition
Other protein-calorie malnutrition - unspecified protein-calorie malnutrition
Other b-complex deficiencies
Disturbances of sulphur-bearing amino-acid metabolism
Pernicious anemia - other specified megaloblastic anemias not elsewhere
classified
281.9
Unspecified deficiency anemia
287.5
Thrombocytopenia unspecified
290.0
Senile dementia uncomplicated
303.91 - 303.92
Other and unspecified alcohol dependence continuous drinking behavior other and unspecified alcohol dependence episodic drinking behavior
331.0
Alzheimer's disease
333.99
Other extrapyramidal diseases and abnormal movement disorders
356.4
Idiopathic progressive polyneuropathy
356.9
Unspecified idiopathic peripheral neuropathy
529.0
Glossitis
529.6
Glossodynia
536.0
Achlorhydria
555.0 - 555.2
Regional enteritis of small intestine - regional enteritis of small intestine with
large intestine
555.9
Regional enteritis of unspecified site
579.0 - 579.4
Celiac disease - pancreatic steatorrhea
579.8 - 579.9
Other specified intestinal malabsorption - unspecified intestinal
malabsorption
780.93
Memory loss
780.99*
Other general symptoms
781.2
Abnormality of gait
781.3
Lack of coordination
782.0
Disturbance of skin sensation
V12.1
Personal history of nutritional deficiency
V45.11
Renal dialysis status
V45.3
Postsurgical intestinal bypass or anastomosis status
V58.11
Encounter for antineoplastic chemotherapy
V58.69
Long-term (current) use of other medications
*Note: Use code 780.99 to identify altered mental status
The following ICD-9 CM codes support the medical necessity of CPT code 84207
266.1
Vitamin b6 deficiency
285.0
Sideroblastic anemia
333.99
Other extrapyramidal diseases and abnormal movement disorders
356.9
Unspecified idiopathic peripheral neuropathy
529.0
Glossitis
The following ICD-9 CM codes support the medical necessity of CPT code 85385
286.3
Congenital deficiency of other clotting factors
34
ASSAYS for VITAMIN and
METABOLIC FUNCTION (LCD)
ASSAYS for VITAMIN and METABOLIC FUNCTION
Medicare A Medical Policy August 13, 2012
286.6 - 286.7
287.30 - 287.33
287.41
287.49
287.5
790.92
Defibrination syndrome - acquired coagulation factor deficiency
Primary thrombocytopenia,unspecified - congenital and hereditary
thrombocytopenic purpura
Posttransfusion purpura
Other secondary thrombocytopenia
Thrombocytopenia unspecified
Abnormal coagulation profile
The following ICD-9 CM codes support the medical necessity of CPT code 86352, 86353
279.10 - 279.13
Immunodeficiency with predominant t-cell defect unspecified - nezelof's
syndrome
996.81 - 996.88
Complications of transplanted kidney - complications of transplanted organ,
stem cell
V42.0
Kidney replaced by transplant
V42.1
Heart replaced by transplant
V42.6
Lung replaced by transplant
V42.7
Liver replaced by transplant
V42.81
Bone marrow replaced by transplant
V42.83
Pancreas replaced by transplant
V42.84
Organ or tissue replaced by transplant intestines
The following ICD-9 CM codes support the medical necessity of CPT code 86141, 83698
414.01
Coronary atherosclerosis of native coronary artery
Reviewed:
April 2013
35
ASSAYS for VITAMIN and
METABOLIC FUNCTION (LCD)
BLOOD COUNTS
National Coverage Decision November 25, 2002
*THIS SECTION ONLY*
***ALL OTHER DIAGNOSIS WILL BE COVERED***
***LISTED BELOW ARE THE DIAGNOSES THAT ARE NOT COVERED***
CPT: 85004
CPT: 85007
CPT: 85008
CPT:
CPT:
CPT:
CPT:
85013
85014
85018
85025
CPT:
CPT:
CPT:
CPT:
85027
85032
85048
85049
Blood count automated differential white blood cell (WBC count
Blood count; manual differential WBC count (includes RBC morphology and
platelet estimation)
Blood counts, manual blood smear examination without differential
parameters
Blood counts, Spun microhematocrit
Blood counts, Other than spun hematocrit
Blood counts, Hemoglobin
Hemogram and platelet count, automated and automated complete
differential WBC count (CBC)
Blood counts, Hemogram and platelet count, automated
Manual cell count (erythrocyte, leukocyte, or platelet) each
Blood counts, White blood cell (WBC)
Platelet, automated
078.10-078.19
210.0-210.9
214.0
216.0-216.9
217
222.0-222.9
224.0
Viral Warts
Benign neoplasm of lip, oral cavity, and pharynx
Benign neoplasm of skin
Benign neoplasm of skin
Benign neoplasm of breast
Benign neoplasm of male genital organs
Benign neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid
230.0
232.0-232.9
300.00-300.09
301.0-301.9
302.0-302.9
307.0
307.20-307.23
307.3
307.80-307.89
312.00-312.9
313.0-313.9
314.00-314.9
338.0-338.4
363.30-363.35
363.40-363.43
363.50-363.57
363.70-363.9
366.00-366.9
367.0-367.9
371.00-371.9
373.00-373.9
375.00-375.9
376.21-376.9
377.10-377.16
377.21-377.24
Carcinoma in situ of lip, oral cavity and pharynx
Carcinoma in situ of skin
Neurotic disorders
Personality disorders
Sexual deviations and disorders
Stammering
Tics
Stereotyped movements disorder
Pain disorders related to psychological factors
Disturbance of conduct, not elsewhere classified
Disturbance of emotions specific to childhood and adolescence
Hyperkinetic syndrome of childhood
Central pain syndrome
Chorioretinal scars
Choroidal degeneration
Hereditary choroidal dystrophies
Choroidal detachment
Cataract
Disorders of refraction and accommodation
Corneal opacity and other disorders of cornea
Inflammation of eyelids
Disorders of lacrimal system
Disorders of the orbit, except 376.3, other exophthalmic conditions
Optic atrophy
Other disorders of optic disc
36
CBC (NCD)
BLOOD COUNTS
National Coverage Decision November 25, 2002
*THIS SECTION ONLY*
***ALL OTHER DIAGNOSIS WILL BE COVERED***
***LISTED BELOW ARE THE DIAGNOSES THAT ARE NOT COVERED***
384.20-384.25
384.81-384.82
385.00-385.9
387.0-387.9
388.00-388.5
389.00-389.9
440.0-440.1
443.81-443.9
448.1
457.0
470
471.0-471.9
478.0
478.4
478.11, 478.19
478.19
520.0-520.9
521.00-521.9
524.00-524.9
525.0-525.9
526.0-526.3
527.6-527.9
575.6
600.00-600.91
603.0
603.8
603.9
605
606.0-606.1
608.1
608.3
608.20-608.24
610.0-610.9
611.1-611.6
611.9
616.2
618.00-618.9
620.0-620.3
621.6-621.7
627.2-627.9
628.0-628.9
676.00-676.94
691.0-691.8
692.0-692.9
700
701.0-701.9
702.0-702.8
703.9
706.0-706.9
Perforation of tympanic membrane
Other specified disorders of tympanic membrane
Other disorders of middle ear and mastoid
Otosclerosis
Other disorders of ear
Hearing Loss
Atherosclerosis of aorta and renal artery
Other and unspecified peripheral vascular disease
Capillary nevus, non neoplastic
Postmastectomy lymphedema syndrome
Deviated nasal septum
Nasal polyps
Hypertrophy of nasal turbinates
Polyp of vocal cord or larynx
Nasal mucositis (ulcerative)
Other disease of nasal cavity and sinuses
Disorders of tooth development and eruption
Diseases of hard tissues of teeth
Dentofacial anomalies, including malocculsion
Other diseases and conditions of teeth and supporting structures
Diseases of the jaws
Disease of salivary glands
Cholesterolosis of gallbladder
Hyperplasia of prostate
Encysted hydrocele
Other specified types of hydrocele
Hydrocele, unspecified
Redundant prepuce and phimosis
Infertility, male azoospermia and oligospremia
Spermatocoele
Atrophy of testis
Torsion of testis
Benign mammary dysplasia
Other disorders of breast
Unspecified breast disorder
Cyst of Bartholin's gland
Genital prolapse
Noninflammatory disorders of ovary, fallopian tube, and broad ligament
Malposition or chronic inversion of uterus
Menopausal and post menopausal disorders
Infertility, female
Other disorders of breast associated with childbirth and disorders of lactation
Atopic dermatitis and related disorders
Contact dermatitis and other eczema
Corns and callosities
Other hypertrophic and atrophic conditions of skin
Other dermatoses
Unspecified disease of nail
Diseases of sebaceous glands
37
CBC (NCD)
BLOOD COUNTS
National Coverage Decision November 25, 2002
*THIS SECTION ONLY*
***ALL OTHER DIAGNOSIS WILL BE COVERED***
***LISTED BELOW ARE THE DIAGNOSES THAT ARE NOT COVERED***
709.00-709.4
715.00-715.98
716.00-716.99
718.00-718.99
726.0-726.91
727.00-727.9
728.10-728.85
732.0-732.9
733.00-733.09
734
735.0-735.9
736.00-736.9
737.0-737.9
738.0-738.9
739.0-739.9
799.81
830.0-832.19
832.2
833.00-833.19
834.00-834.12
835.00-835.13
836.0-836.69
837.0-837.1
838.00-838.19
839.00-839.9
840.0-848.9
905.0-909.9
910.0-919.9
930.0-932
955.0-957.9
V03.0-V06.9
V11.0-V11.3
Other disorders of skin and subcutaneous tissue
Osteoarthrosis
Other and unspecified arthropathies
Other derangement of joint
Peripheral esthesiopathies and allied syndromes
Other disorders of synovium, tendon, and bursa
Disorders of muscle ligament and fascia
Osteochondropathies
Osteoporosis
Flat foot
Acquired deformities of toe
Other acquired deformities of limb
Curvature of spine
Other acquired deformity
Nonallopathic lesions, not elsewhere classified
Decreased libido
Dislocation of jaw, shoulder, and elbow
Nursemaid's elbow
Dislocation of wrist
Dislocation of finger
Dislocation of hip
Dislocation of knee
Dislocation of ankle
Dislocation of foot
Other, multiple and ill-defined dislocations
Sprains and strains of joints and adjacent muscles
Late effects of musculoskeletal and connective tissue injuries
Superficial injuries
Foreign body on external eye, in ear, in nose
Injury to peripheral nerve
Need for prophylactic vaccination
Personal history of mental disorder; schizophrenia, affective disorders,
neurosis, and alcoholism
V11.4
Personal history of combat and operational stress reaction
V11.8-V11.9
Personal history of other and unspecified mental disorders
V14.0-V14.8
Personal history of allergy to medicinal agents
V16.0
Family history of malignant neoplasm, gastrointestinal tract
V16.3
Family history of malignant neoplasm, breast
V16.52
Family history of malignant neoplasm, bladder
V21.0-V21.9
Consitutional states in development
V25.01-V25.04, V25.9 Encounter for contraceptive management
V25.11
Encounter for insertion of intrauterine contraceptive device
V25.12
Encounter for removal of intrauterine contraceptive device
V25.13
Encounter for removal and reinsertion of intrauterine contraceptive device
V25.2-V25.3, V25.40- Encounter for sterilization; menstrual extraction; surveillance of previously
V25.43, V25.49, V25.5, prescribed contraceptive methods; and insertion of implantable subdermal
V25.8, V25.9
contraceptive; other specified and unspecified contraceptive management
V26.0-V26.9
Procreative management
38
CBC (NCD)
BLOOD COUNTS
National Coverage Decision November 25, 2002
*THIS SECTION ONLY*
***ALL OTHER DIAGNOSIS WILL BE COVERED***
***LISTED BELOW ARE THE DIAGNOSES THAT ARE NOT COVERED***
V40.0-V40.9
V41.0-V41.9
V43.0-V43.1
V44.0-V44.9
V45.00-V45.89
V48.0-V48.9
V49.0-V49.85
V49.86
V49.87
V49.89-V49.9
V51.0
V51.8
V52.0-V52.9
V53.01-V53.09
V53.1
V53.31-V53.39
V53.4
V53.50
V53.51
V53.59
V53.5
V53.6
V53.7
V53.8
V53.90-V53.99
V54.01-V54.9
V55.0-V55.9
V57.0-V57.9
V58.5
V59.01-V59.9
V61.0-V61.09
V61.09
V61.10
V61.12
V61.20
V61.21
V61.22
V61.23
V61.24
V61.25
V61.29
V61.3
V61.41
V61.42
V61.49, V61.5-V61.9
V62.21
V62.22
V62.29
Mental and behavioral problems
Problems with special senses and other special functions
Organ or tissue replaced by other means, eye globe or lens
Artificial opening status
Other post surgical states
Problems with head, neck and trunk
Other conditions influencing health status
Do not resuscitate status
Physical restraints status
Other specified and unspecified conditions influencing health status
Encounter for breast reconstruction following mastectomy
Other aftercare involving the use of plastic surgery
Fitting and adjustment of prosthetic device and implant
Fitting and adjustment of devices related to nervous system and special
senses
Fitting and adjustment of spectacles and contact lenses
Fitting and adjustment of cardiac device
Fitting and adjustment of orthodontic devices
Fitting and adjustment of intestinal appliance or device
Fitting and adjustment of gastric lap band
Fitting and adjustment of other gastrointestinal appliance and device
Fitting and adjustment of other intestinal appliance
Fitting and adjustment of urinary devices
Fitting and adjustment of orthopedic devices
Fitting and adjustment of wheelchair
Fitting and adjustment of other and unspecified device
Other orthopedic aftercare
Attention to artificial openings
Care involving use of rehabilitation procedures
Orthodontics
Donors
Other family circumstances
Other family disruption
Counseling for marital and partner problems, unspecified
Counseling for perpetrator of spousal and partner abuse
Counseling for parent-child problem
Counseling for victim of child abuse
Counseling for perpetrator of parental child abuse
Counseling for parent-biological child problem
Counseling for parent-adopted child problem
Counseling for parent (guardian)-foster child problem
Other parent-child problems (Description Revised 10/09)
Problems with aged parents or in-laws
Alcoholism in family
Substance abuse in family
Other specified and unspecified family problems
Personal current military deployment status
Personal history of return from military deployment
Other occupational circumstances or maladjustment
39
CBC (NCD)
BLOOD COUNTS
National Coverage Decision November 25, 2002
*THIS SECTION ONLY*
***ALL OTHER DIAGNOSIS WILL BE COVERED***
***LISTED BELOW ARE THE DIAGNOSES THAT ARE NOT COVERED***
V62.3-V62.84
V62.85
V62.89-V62.9
V65.2
Educational circumstances; other psychological or physical stress, not
elsewhere classified; suicidal ideation
Homicidal ideation
Other psychological or physical stress, not elsewhere classified; and
unspecified psychosocial circumstances
Person feigning illness
V72.9
V73.81
V76.10-V76.19
V76.2
V76.44
V76.51
V77.1
V81.0-V81.2
Dietary surveillance and counseling
Other counseling, not elsewhere classified
Person with feared complaint in whom no diagnosis was made
Other reasons for seeking consultation
Unspecified reason for consultation
Convalescence and palliative care
Follow-up examination following psychotherapy
Follow-up examination following treatment of healed fracture
Problems related to lifestyle, gambling and betting
Routine general examination
Observation and evaluation for suspected conditions not found, mental
Special investigations, examination of eyes and vision, ears and hearing,
dental
Special investigations, pregnancy exam, radiologic exam, laboratory exam,
diagnostic skin and sensitization tests
Special investigation, unspecified
Special screening exam for Human papillomavirus (HPV)
Special screening for malignant neoplasms, breast
Special screening for malignant neoplasms, cervix
Special screening for malignant neoplasms, prostate
Special screening for malignant neoplasms. Intestine, colon
Special screening for diabetes mellitus
Special screening for cardiovascular disease
Reviewed:
April 2013
V65.3
V65.40-V65.49
V65.5
V65.8
V65.9
V66.0-V66.9
V67.3
V67.4
V69.3
V70.0
V71.01-V71.09
V72.0-V72.2
V72.40-V72.7
40
CBC (NCD)
B-TYPE NATRIURETIC PEPTIDE (BNP)
Medicare A Medical Policy August 13, 2012
CPT: 83880
Assay of natriuretic peptide
402.01
402.11
402.91
404.01
411.1
428.0
428.1
428.20
428.21
428.22
428.23
428.30
428.31
428.32
428.33
428.40
428.41
428.42
428.43
428.9
786.00
786.02
786.05
786.06
786.07
786.09
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-IV, or unspecified
Hypertensive heart and chronic kidney disease, malignant, with heart failure
and with chronic kidney disease stage V or End Stage Renal Disease
Hypertensive heart and chronic kidney disease, benign, with heart failure and
with chronic kidney disease stage I-IV, or unspecified
Hypertensive heart and chronic kidney disease, benign, with heart failure and
with chronic kidney disease stage V or End Stage Renal Disease
Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and with chronic kidney disease stage I-IV, or unspecified
Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and with chronic kidney disease stage V or End Stage Renal Disease
Acute myocardial infarction of anterolateral wall episode of care unspecified actue myocardial infarction of unspecified site subsequent episode of care
Intermediate coronary syndrome
Congestive heart failure unspecified
Left heart failure
Unspecified systolic heart failure
Acute systolic heart failure
Chronic systolic heart failure
Acute on Chronic systolic heart failure
Unspecified diastolic heart failure
Acute diastolic heart failure
Chronic diastolic heart failure
Acute on Chronic diastolic heart failure
Unspecified combined systolic and diastolic heart failure
Acute combined systolic and diastolic heart failure
Chronic combined systolic and diastolic heart failure
Acute on chronic combined systolic and diastolic heart failure
Heart failure unspecified
Respiratory abnormality unspecified
Orthopnea
Shortness of breath
Tachypnea
Wheezing
Respiratory abnormality other
Reviewed:
April 2013
404.03
404.11
404.13
404.91
404.93
410.00-410.92
41
BNP (LCD)
CA125
National Coverage Decision November 25, 2002
CPT: 86304
Immunoassay for tumor antigen, quantitative, CA125
158.8-158.9
180.0
182.0
183.0
183.2
183.8
184.8
198.6
198.82
236.0-236.3
338.3
789.39
795.82
795.89
V10.41-V10.42
V10.43-V10.44
Malignant neoplasms, peritoneum, unspecified
Malignant neoplasm, endocervix
Malignant neoplasm of corpus uteri, except isthmus
Malignant neoplasm, ovary
Malignant neoplasm, fallopian tube
Malignant neoplasm, other specified sites of uterine adnexa
Malignant neoplasm, other specified sites of female genital organs
Secondary malignant neoplasm, ovary
Secondary malignancy of genital organs
Neoplasm of uncertain behavior of female genital organs
Neoplasm related pain (acute)(chronic)
Abdominal or pelvic swelling, mass, or lump, other specified site
Elevated cancer antigen 125 (CA 125)
Other abnormal tumor markers
Personal history of malignant neoplasm, other parts of uterus
Personal history of malignant neoplasm of female genital organs
Reviewed:
April 2013
42
CA 125 (NCD)
CA 15-3 / CA 27.29
National Coverage Decision November 25, 2002
CPT: 86300
Immunoassay for tumor antigen, quantitative, CA15-3 / CA 27.29
174.0-174.9
Breast, primary (female) - malignant neoplasm of female breast
175.0-175.9
198.2
198.81
338.3
795.89
V10.3
Breast, primary (male) - malignant neoplasm of male breast
Secondary malignant neoplasm (breast)
Secondary malignant neoplasm (breast)
Neoplasm related pain (acute)(chronic)
Other abnormal tumor markers
Personal history of malignant neoplasm, breast
Reviewed:
April 2013
43
CA 15-3 / CA 27.29 (NCD)
CA 19-9
National Coverage Decision November 25, 2002
CPT: 86301
Immunoassay for tumor antigen, quantitative, CA19-9
155.1
156.0
156.1
156.2
156.8
156.9
157.0-157.9
197.8
235.3
235.5
Malignant neoplasm, intrahepatic bile ducts
Malignant neoplasm, gallbladder
Malignant neoplasm, extrahepatic bile ducts
Malignant neoplasm, ampulla of Vater
Malignant neoplasm, other specified sites of gallbladder and extrahepatic bile
ducts
Malignant neoplasm, unspecified part of biliary tract
Malignant neoplasm, pancreas
Secondary malignant neoplasm, other digestive organs and spleen
Neoplasm of uncertain behavior, liver and biliary passages
Neoplasm of uncertain behavior, other and unspecified digestive organs
338.3
795.89
V10.09
Neoplasm related pain (acute)(chronic)
Other abnormal tumor markers
Other personal history of cancer
Reviewed:
April 2013
44
CA 19-9 (NCD)
CARCINOEMBRYONIC ANTIGEN (CEA)
National Coverage Decision November 25, 2002
CPT: 82378
Carcinoembryonic Antigen
150.0-150.9
Malignant neoplasm of the esophagus
151.0-151.9
Malignant neoplasm of stomach
152.0-154.8
Malignant neoplasm of small intestine, including duodenum, rectum,
157.0-157.9
Primary malignancy of pancreas
159.0
Malignant neoplasm of intestinal tract, part unspecified
162.0-162.9
Malignant neoplasm of trachea, bronchus, lung
174.0-174.9
Malignant neoplasm of female breast
175.0-175.9
Malignant neoplasm of male breast
183.0
Malignant neoplasm of ovary
197.0
Secondary malignant neoplasm of lung
197.4
Secondary malignant neoplasm of small intestine
197.5
Secondary malignant neoplasm of large intestine and rectum
209.00-209.03
Malignant carcinoid tumors of the small intestine
209.10-209.17
Malignant carcinoid tumors of the appendix, large intestine and rectum
209.20-209.29
Malignant carcinoid tumors of other and unspecified sites
209.70
Secondary neuroendocrine tumor, unspecified site
209.71
Secondary neuroendocrine tumor of distant lymph nodes
209.72
Secondary neuroendocrine tumor of liver
209.73
Secondary neuroendocrine tumor of bone
209.74
Secondary neuroendocrine tumor of peritoneum
209.75
Secondary Merkel cell carcinoma
209.79
Secondary neuroendocrine tumor of other sites
230.3
Carcinoma in situ of colon
230.4
Carcinoma in situ of rectum
230.7
Carcinoma in situ of other/unspecified parts of intestine
230.9
Carcinoma in situ other and unspecified digestive organs
235.2
Neoplasm of uncertain behavior of stomach, intestines, rectum
338.3
Neoplasm related pain (acute) (chronic)
790.99
Other nonspecific findings on examination of blood
795.81
Elevated Carcinoembryonic Antigen (CEA)
795.89
Other abnormal tumor markers
V10.00
Personal history of malignant neoplasm of gastro-intestinal tract, unspecified
V10.05
Personal history of malignant neoplasm, large intestine
V10.06
Personal history of malignant neoplasm, rectum, rectosigmoid junction, anus
V10.11
Personal history of malignant neoplasm, bronchus, and lung
V10.3
Personal history of malignant neoplasm, breast
V10.43
Personal history of malignant neoplasm, ovary
V67.2
Follow-up examination following chemotherapy
Reviewed:
April 2013
45
CEA (NCD)
CIRCULATING TUMOR CELL ASSAY
Medicare A Medical Policy August 13, 2012
CPT: 86849
Immunology procedure
203.00
203.02
Multiple myeloma, without mention of having achieved remission
Multiple myeloma, in relapse
Reviewed:
April 2013
46
CTCA (LCD)
COLLAGEN CROSS LINKS (NTX)
National Coverage Decision November 25, 2002
CPT: 82523
Collagen cross links, any method
242.00-242.91
245.2
246.9
252.00-252.02
252.08
256.2
256.31-256.39
256.8
256.9
268.9
269.3
627.0
627.1
627.2
627.4
627.8
627.9
731.0
733.00-733.09
733.10-733.19
733.90
805.8
V58.65
V58.69
Thyrotoxicosis
Chronic lymphocytic thyroiditis (only if thyrotoxic)
Unspecified disorder of thyroid
Hyperparathyroidism
Hyperparathyroidism
Postablative ovarian failure
Other ovarian failure
Other ovarian dysfunction
Unspecified ovarian dysfunction
Unspecified vitamin D deficiency
Mineral deficiency, not elsewhere classified
Premenopausal menorrhagia
Postmenopausal bleeding
Menopausal or female climacteric state
States associated with artificial menopause
Other specified menopausal and postmenopausal disorders
Unspecified menopausal & postmenopausal disorder
Osteitis deformans without mention of bone tumor (Paget's disease of bone)
Osteoporosis
Pathological fracture
Disorder of bone and cartilage, unspecified
Fracture of vertebral column without mention of spiral cord injury,
unspecified, closed
Long-term (current) use of steroids
Long-term (current) use of other medications
Reviewed:
April 2013
47
COLLAGEN CROSS LINKS
NTX (NCD)
DIGOXIN THERAPEUTIC DRUG ASSAY (ANY SOURCE)
National Coverage Decision November 25, 2002
CPT: 80162
Digoxin
242.00-242.91
275.40-275.49
Thyrotoxicosis with or without goiter
Congenital hypothyroidism
Acquired hypothyroidism
Thyroiditis
Disorders of magnesium metabolism
Disorders of calcium metabolism
275.5
Hungry bone syndrome
276.0
307.47
Hyperosmolality
Hyposmolality
Acidosis
Alkalosis
Mixed acid-base balance disorder
Volume depletion
Transfusion associated circulatory overload
Other fluid overload
Hyperpotassemia
Hypopotassemia
Electrolyte and fluid Disorder (not elsewhere classified)
Acute delirium
Subacute delirium
Other dysfunctions of sleep stages or arousal from sleep
339.3
Drug induced headache, not elsewhere classified
368.16
Psychopysical visual disturbances
Other specified visual disturbances
Unspecified visual disturbances
Rheumatic diseases of endocardium
Rheumatic Myocarditis
Rheumatic Hearth Failure
Hypertensive heart disease, malignant with CHF
Hypertensive heart disease, benign with CHF
Hypertensive heart disease, unspecified with CHF
Hypertensive renal disease
Hypertensive heart and renal disease
Acute myocardial infarction
Other acute and subacute forms of ischemic heart disease
Angina pectoris
Coronary atherosclerosis due to calcified coronary lesion
Acute myocarditis
Cardiomyopathy
243
244.0-244.9
245.0-245.9
275.2
276.1
276.2
276.3
276.4
276.50-276.52
276.61
276.69
276.7
276.8
276.9
293.0
293.1
368.8
368.9
397.9
398.0
398.91
402.01
402.11
402.91
403.00-403.91
404.00-404.93
410.00-410.92
411.0-411.89
413.0-413.9
414.4
422.0-422.99
425.0, 425.11, 425.18
425.2-425.9
48
DIGOXIN (NCD)
DIGOXIN THERAPEUTIC DRUG ASSAY (ANY SOURCE)
National Coverage Decision November 25, 2002
588.1
Conduction disorders
Cardiac dysrhythmias
Heart failure
Cardiovascular disease, unspecified
Heart Disturbances Postcardiac Surgery
Rupture chordae tenineae
Rupture papillary muscle
Acquired cardiac septal defect
Saddle embolus of abdominal aorta
Other arterial embolism and thrombosis of abdominal aorta
Pulmonary congestion and hypostasis
Hepatopulmonary syndrome
Unspecified intestinal malabsorption
Acute renal failure
Chronic renal failure
Renal Failure, unspecified
Renal sclerosis, unspecified
Renal osteodystrophy
Nephrogenic Diabetes Insipidus
588.81, 588.89
Impaired renal function (not elsewhere classified)
588.9
799.21
Unspecified disorder resulting from impaired renal function
Coma
Transient alteration of awareness
Other ill-defined general symptoms (drowsiness, semicoma, somnolence,
stupor, unconsciousness)
Hallucinations
Syncope & collapse
Dizziness and giddiness
Malaise and fatigue
Anorexia
Headache
Nausea and vomiting
Bilious emesis
Diarrhea
Abnormal electrocardiogram
Nervousness
799.22
Irritability
799.23
Impulsiveness
799.24
Emotional lability
799.25
Demoralization and apathy
799.29
Other signs and symptoms involving emotional state
426.0-426.9
427.0-427.9
428.0-428.9
429.2
429.4
429.5
429.6
429.71
444.01
444.09
514
573.5
579.9
584.5-584.9
585.1-585.9
586
587
588.0
780.01
780.02
780.09
780.1
780.2
780.4
780.71-780.79
783.0
784.0
787.01-787.03
787.04
787.91
794.31
49
DIGOXIN (NCD)
DIGOXIN THERAPEUTIC DRUG ASSAY (ANY SOURCE)
National Coverage Decision November 25, 2002
972.1
Poisoning by cardiac rhythm regulators
Poisoning by cardiotonic glycosides and drugs of similar action
995.20
Unspecified adverse effect of unspecified drug, medicinal and biological
995.21
Arthus phenomenon
995.24
Failed moderate sedation during procedure
995.27
Other drug allergy
995.29
Unspecified adverse effect of other drug, medicinal and biological substance
**E942.1
V58.69
Adverse effect of cardiotonic glycosides and drugs of similar action
Encounter long term medication use (not elsewhere classified)
**
Code may not be reported as a stand-alone or first-listed code on the claim.
Reviewed:
April 2013
972.0
50
DIGOXIN (NCD)
FLOW CYTOMETRY
Medicare A Medical Policy August 13, 2012
CPT:
CPT:
CPT:
CPT:
CPT:
CPT:
88182
88184
88185
88187
88188
88189
Cell marker study
Flowcytomety/tc 1 marker
Flowcytometry/tc add-on
Flowcytometry/read 2-8
Flowcytometry/read 9-15
Flowcytometry/read 16 & >
The following ICD-9 CM codes support the medical necessity of CPT code 88184, 88185, 88187,
88188, 88189
042
Human immunodeficiency virus (hiv) disease
079.51 - 079.53
Human t-cell lymphotrophic virus type i [htlv-i] - human immunodeficiency
virus type 2 [hiv-2]
197.2
Secondary malignant neoplasm of pleura
197.6
Secondary malignant neoplasm of retroperitoneum and peritoneum
200.00 - 200.08
Reticulosarcoma unspecified site - reticulosarcoma involving lymph nodes of
multiple sites
200.10 - 200.18
Lymphosarcoma unspecified site - lymphosarcoma involving lymph nodes of
multiple sites
200.20 - 200.28
Burkitt's tumor or lymphoma unspecified site - burkitt's tumor or lymphoma
involving lymph nodes of multiple sites
200.30 - 200.38
Marginal zone lymphoma, unspecified site, extranodal and solid organ sites marginal zone lymphoma, lymph nodes of multiple sites
200.40 - 200.48
Mantle cell lymphoma, unspecified site, extranodal and solid organ sites 200.50 - 200.58
Primary central nervous system lymphoma, unspecified site, extranodal and
solid organ sites - primary central nervous system lymphoma, lymph nodes of
multiple sites
200.60 - 200.68
Anaplastic large cell lymphoma, unspecified site, extranodal and solid organ
sites - anaplastic large cell lymphoma, lymph nodes of multiple sites
200.70 - 200.78
Large cell lymphoma, unspecified site, extranodal and solid organ sites large cell lymphoma, lymph nodes of multiple sites
200.80 - 200.88
Other named variants of lymphosarcoma and reticulosarcoma unspecified
site - other named variants of lymphosarcoma and reticulosarcoma involving
lymph nodes of multiple sites
201.00 - 201.08
Hodgkin's paragranuloma unspecified site - Hodgkin's paragranuloma
involving lymph nodes of multiple sites
201.10 - 201.18
Hodgkin's granuloma unspecified site - Hodgkin's granuloma involving lymph
nodes of multiple sites
201.20 - 201.28
Hodgkin's sarcoma unspecified site - Hodgkin's sarcoma involving lymph
nodes of multiple sites
201.40 - 201.48
Hodgkin's disease lymphocytic-histiocytic predominance unspecified site Hodgkin's disease lymphocytic-histiocytic predominance involving lymph
nodes of multiple sites
201.50 - 201.58
Hodgkin's disease nodular sclerosis unspecified site - Hodgkin's disease
201.60 - 201.68
Hodgkin's disease mixed cellularity unspecified site - Hodgkin's disease
mixed cellularity involving lymph nodes of multiple sites
201.70 - 201.78
Hodgkin's disease lymphocytic depletion unspecified site - Hodgkin's disease
lymphocytic depletion involving lymph nodes of multiple sites
201.90 - 201.98
Hodgkin's disease unspecified type unspecified site - Hodgkin's disease
unspecified type involving lymph nodes of multiple sites
51
FLOW CYTOMETRY (NCD)
FLOW CYTOMETRY
Medicare A Medical Policy August 13, 2012
202.00 - 202.08
202.10 - 202.18
202.20 - 202.28
202.30 - 202.38
202.40 - 202.48
202.50 - 202.58
202.60 - 202.68
202.70 - 202.78
202.80 - 202.88
202.90 - 202.98
203.00
203.02
203.10 - 203.12
203.80 - 203.82
204.00 - 204.02
204.10 - 204.12
204.20 - 204.22
204.80 - 204.82
204.90 - 204.92
205.00 - 205.02
205.10 - 205.12
205.20 - 205.22
205.30 - 205.32
205.80 - 205.82
205.90 - 205.92
206.00 - 206.02
206.10 - 206.12
206.20 - 206.22
Nodular lymphoma unspecified site - nodular lymphoma involving lymph
nodes of multiple sites
Mycosis fungoides unspecified site - mycosis fungoides involving lymph
Sezary's disease unspecified site - Sezary's disease involving lymph nodes of
multiple sites
Malignant histiocytosis unspecified site - malignant histiocytosis involving
lymph nodes of multiple sites
Leukemic reticuloendotheliosis unspecified site - leukemic
Letterer-siwe disease unspecified site - Letterer-siwe disease involving lymph
nodes of multiple sites
Malignant mast cell tumors unspecified site - malignant mast cell tumors
involving lymph nodes of multiple sites
Peripheral t cell lymphoma, unspecified site, extranodal and solid organ sites peripheral t cell lymphoma, lymph nodes of multiple sites
Other malignant lymphomas unspecified site - other malignant lymphomas
involving lymph nodes of multiple sites
Other and unspecified malignant neoplasms of lymphoid and histiocytic
tissue unspecified site - other and unspecified malignant neoplasms of
lymphoid and histiocytic tissue involving lymph nodes of multiple sites
Multiple myeloma, without mention of having achieved remission
Multiple myeloma, in relapse
Plasma cell leukemia, without mention of having achieved remission - plasma
cell leukemia, in relapse
Other immunoproliferative neoplasms, without mention of having achieved
remission - other immunoproliferative neoplasms, in relapse
Acute lymphoid leukemia, without mention of having achieved remission acute lymphoid leukemia, in relapse
Chronic lymphoid leukemia, without mention of having achieved remission chronic lymphoid leukemia, in relapse
Subacute lymphoid leukemia, without mention of having achieved remission Other lymphoid leukemia, without mention of having achieved remission other lymphoid leukemia, in relapse
Unspecified lymphoid leukemia, without mention of having achieved
remission - unspecified lymphoid leukemia, in relapse
Acute myeloid leukemia, without mention of having achieved remission acute myeloid leukemia, in relapse
Chronic myeloid leukemia, without mention of having achieved remission chronic myeloid leukemia, in relapse
Subacute myeloid leukemia, without mention of having achieved remission subacute myeloid leukemia, in relapse
Myeloid sarcoma, without mention of having achieved remission - myeloid
Other myeloid leukemia, without mention of having achieved remission other myeloid leukemia, in relapse
Unspecified myeloid leukemia, without mention of having achieved remission
- unspecified myeloid leukemia, in relapse
Acute monocytic leukemia, without mention of having achieved remission acute monocytic leukemia, in relapse
Chronic monocytic leukemia, without mention of having achieved remission chronic monocytic leukemia, in relapse
Subacute monocytic leukemia, without mention of having achieved remission
- subacute monocytic leukemia, in relapse
52
FLOW CYTOMETRY (NCD)
FLOW CYTOMETRY
Medicare A Medical Policy August 13, 2012
206.80 - 206.82
282.7
283.2
284.01
284.09
284.11 - 284.12
284.19
284.2
284.81
284.89
284.9
285.0
285.22
285.8 - 285.9
287.30 - 287.33
Other monocytic leukemia, without mention of having achieved remission other monocytic leukemia, in relapse
Unspecified monocytic leukemia, without mention of having achieved
remission - unspecified monocytic leukemia, in relapse
Acute erythremia and erythroleukemia, without mention of having achieved
remission - acute erythremia and erythroleukemia, in relapse
Chronic erythremia, without mention of having achieved remission - chronic
erythremia, in relapse
Megakaryocytic leukemia, without mention of having achieved remission Other specified leukemia, without mention of having achieved remission other specified leukemia, in relapse
Acute leukemia of unspecified cell type, without mention of having achieved
remission - acute leukemia of unspecified cell type, in relapse
Chronic leukemia of unspecified cell type, without mention of having
achieved remission - chronic leukemia of unspecified cell type, in relapse
Subacute leukemia of unspecified cell type, without mention of having
achieved remission - subacute leukemia of unspecified cell type, in relapse
Other leukemia of unspecified cell type, without mention of having achieved
remission - other leukemia of unspecified cell type, in relapse
Unspecified leukemia, without mention of having achieved remission unspecified leukemia, in relapse
Essential thrombocythemia - post-transplant lymphoproliferative disorder
(ptld)
Other lymphatic and hematopoietic tissues
Monoclonal paraproteinemia - macroglobulinemia
Other disorders of plasma protein metabolism - unspecified disorder of
plasma protein metabolism
Hypogammaglobulinemia unspecified - common variable immunodeficiency
Other deficiency of humoral immunity
Immunodeficiency with predominant t-cell defect unspecified - nezelof's
Other deficiency of cell-mediated immunity
Combined immunity deficiency - unspecified immunity deficiency
Autoimmune lymphoproliferative syndrome
Autoimmune disease, not elsewhere classified
Other specified disorders involving the immune mechanism - unspecified
disorder of immune mechanism
Other hemoglobinopathies
Hemoglobinuria due to hemolysis from external causes
Constitutional red blood cell aplasia
Other constitutional aplastic anemia
Antineoplastic chemotherapy induced pancytopenia - other drug induced
Other pancytopenia
Myelophthisis
Red cell aplasia (acquired) (adult) (with thymoma)
Other specified aplastic anemias
Aplastic anemia unspecified
Sideroblastic anemia
Anemia in neoplastic disease
Other specified anemias - anemia unspecified
Primary thrombocytopenia,unspecified - congenital and hereditary
287.39
Other primary thrombocytopenia
206.90 - 206.92
207.00 - 207.02
207.10 - 207.12
207.20 - 207.22
207.80 - 207.82
208.00 - 208.02
208.10 - 208.12
208.20 - 208.22
208.80 - 208.82
208.90 - 208.92
238.71 - 238.77
238.79
273.1 - 273.3
273.8 - 273.9
279.00 - 279.06
279.09
279.10 - 279.13
279.19
279.2 - 279.3
279.41
279.49
279.8 - 279.9
53
FLOW CYTOMETRY (NCD)
FLOW CYTOMETRY
Medicare A Medical Policy August 13, 2012
287.5
288.00 - 288.04
288.09
288.1 - 288.4
288.50 - 288.51
288.59
288.60 - 288.65
288.69
288.8 - 288.9
289.4
289.50 - 289.53
289.59
289.83
289.9
452
453.9
785.6
789.2
791.0
795.4
996.80 - 996.89
V08
V10.60 - V10.63
V10.69
V10.91
V42.0 - V42.7
V42.81 - V42.84
V42.89
V42.9
Thrombocytopenia unspecified
Neutropenia, unspecified - neutropenia due to infection
Other neutropenia
Functional disorders of polymorphonuclear neutrophils - hemophagocytic
syndromes
Leukocytopenia, unspecified - lymphocytopenia
Other decreased white blood cell count
Leukocytosis, unspecified - basophilia
Other elevated white blood cell count
Other specified disease of white blood cells - unspecified disease of white
Hypersplenism
Disease of spleen unspecified - neutropenic splenomegaly
Other diseases of spleen
Myelofibrosis
Unspecified diseases of blood and blood-forming organs
Portal vein thrombosis
Embolism and thrombosis of unspecified site
Enlargement of lymph nodes
Splenomegaly
Proteinuria
Other nonspecific abnormal histological findings
Complications of unspecified transplanted organ - complications of other
specified transplanted organ
Asymptomatic human immunodeficiency virus (hiv) infection status
Personal history of unspecified leukemia - personal history of monocytic
leukemia
Personal history of other leukemia
Personal history of malignant neuroendocrine tumor
Kidney replaced by transplant - liver replaced by transplant
Bone marrow replaced by transplant - organ or tissue replaced by transplant
intestines
Other specified organ or tissue replaced by transplant
Unspecified organ or tissue replaced by transplant
The following ICD-9 CM codes support the medical necessity of CPT code 88182
150.0 - 150.5
150.8 - 150.9
151.0 - 151.6
151.8 - 151.9
153.0 - 153.9
154.0
154.1
174.0 - 174.6
174.8 - 174.9
175.0
Malignant neoplasm of cervical esophagus - malignant neoplasm of lower
third of esophagus
Malignant neoplasm of other specified part of esophagus - malignant
Malignant neoplasm of cardia - malignant neoplasm of greater curvature of
stomach unspecified
Malignant neoplasm of other specified sites of stomach - malignant neoplasm
of stomach unspecified site
Malignant neoplasm of hepatic flexure - malignant neoplasm of colon
Malignant neoplasm of rectosigmoid junction
Malignant neoplasm of rectum
Malignant neoplasm of nipple and areola of female breast - malignant
neoplasm of axillary tail of female breast
Malignant neoplasm of other specified sites of female breast - malignant
neoplasm of breast (female) unspecified site
Malignant neoplasm of nipple and areola of male breast
54
FLOW CYTOMETRY (NCD)
FLOW CYTOMETRY
Medicare A Medical Policy August 13, 2012
175.9
183.0
183.8
Malignant neoplasm of other and unspecified sites of male breast
Malignant neoplasm of ovary
Malignant neoplasm of other specified sites of uterine adnexa
185
188.0
188.1 - 188.9
193
194.0
198.81
227.0
233.0
259.2
Malignant neoplasm of prostate
Malignant neoplasm of trigone of urinary bladder
Malignant neoplasm of dome of urinary bladder - malignant neoplasm of
bladder part unspecified
Malignant neoplasm of thyroid gland
Malignant neoplasm of adrenal gland
Secondary malignant neoplasm of breast
Benign neoplasm of adrenal gland
Carcinoma in situ of breast
Carcinoid syndrome
Reviewed:
April 2013
55
FLOW CYTOMETRY (NCD)
GAMMA GLUTAMYLTRANSFERASE (GGT)
National Coverage Decision November 25, 2002
CPT: 82977
Glutamyltransferase, gamma (GGT)
003.1
006.0-006.9
014.00-014.86
017.90-017.96
018.90-018.96
020.0-020.9
022.3
027.0
027.1
030.1
032.83
036.1
036.2
038.0-038.9
039.2
040.0
042
054.0
054.5
060.0-060.1
070.0-070.9
072.71
073.0
074.8
075
078.5
079.99
082.0-082.9
084.9
086.1
088.81
091.62
095.3
100.0
112.5
115.00
120.9
121.1
121.3
122.0
122.5
122.8
122.9
130.5
135
150.0-159.9
160.0-165.9
170.0-176.9
Salmonella septicemia
Amebiasis
Tuberculosis of intestines, peritoneum, and mesenteric glands
Tuberculosis of other organs
Miliary tuberculosis, unspecified
Plague
Anthrax septicemia
Listeriosis
Erysipelothrix infection
Tuberculoid leprosy (Type T)
Diptheritic peritonitis
Meningococcal encephalitis
Meningococcemia
Septicemia
Actinomycotic infections, abdominal
Gas gangrene
Human immunodeficiency virus (HIV) disease
Eczema herpeticum
Herpetic septicemia
Yellow fever
Viral hepatitis
Mumps
Ornithosis, with pneumonia
Specific diseases due to Coxsackie virus
Infectious mononucleosis
Other diseases due to viruses and Chlamydiae
Unspecified viral infection
Tick-borne rickettsioses, stet
Malaria
Chagas disease with organ involvement other than heart
Lyme disease
Secondary syphilitic hepatitis
Syphilis of liver
Leptospirosis icterohemorrhagica
Candidiasis, disseminated
Infection by Histoplasm capsulatum without mention of manifestation
Schistosomiasis, unspecified
Clonorchiasis
Fascioliasis
Echinococcus granulosus infection of liver
Echinococcus multilocularis infection of liver
Echinococcosis, unspecified, of liver
Echinococcus, other and unspecified
Hepatitis due to toxoplasmosis
Sarcoidosis
Malignant neoplasm of digestive organs and peritoneum
Malignant neoplasm of respiratory and intrathoracic organs
Malignant neoplasm of bone, connective tissue, skin, and breast
56
GGT (NCD)
GAMMA GLUTAMYLTRANSFERASE (GGT)
National Coverage Decision November 25, 2002
179-189.9
200.00-208.92
209.20-209.29
209.70
209.71
209.72
209.73
209.74
209.75
209.79
211.5
211.6
211.7
228.04
230.7
230.8
230.9
235.0-235.9
236.0-236.99
237.73
237.79
237.9
Malignant neoplasm of genitourinary organs
Malignant neoplasm of lymphatic and hematopoietic tissue
Malignant carcinoid tumors of other and unspecified sites
Secondary neuroendocrine tumor, unspecified site
Secondary neuroendocrine tumor of distant lymph nodes
Secondary neuroendocrine tumor of liver
Secondary neuroendocrine tumor of bone
Secondary neuroendocrine tumor of peritoneum
Secondary Merkel cell carcinoma
Secondary neuroendocrine tumor of other sites
Benign neoplasm of liver and biliary passages
Benign neoplasm of pancreas, except islets of Langerhans
Benign neoplasm of islets of Langerhans
Hemangioma of intrac-abdominal structures
Carcinoma in situ of other and unspecified parts of intestine
Carcinoma in situ of liver and biliary system
Carcinoma in situ other and unspecified digestive organs
Neoplasms of uncertain behavior of digestive and respiratory systems
Neoplasms of uncertain behavior of genitourinary organs
Schwannomatosis
Other neurofibromatosis
Neoplasms of uncertain behavior of other and uncertain parts of the nervous
system
238.0-238.6
Neoplasms of uncertain behavior of other and unspecified sites and tissues
238.71-238.76
Neoplasms of other lymphatic and hematopoietic tissues
238.77
Post-transplant lymphoproliferative disorder (PTLD)
238.79
Neoplasm of uncertain behavior
238.8
Neoplasms of uncertain behavior of other specified sites
238.9
Neoplasms of uncertain behavior of unspecified sites
239.0
Neoplasm of unspecified nature of digestive system
250.00-250.93
Diabetes mellitus
252.00-252.02, 252.08 Hyperparathyroidism
263.1
Malnutrition of mild degree
263.9
Unspecified protein-calorie malnutrition
268.0
Rickets, active
268.2
Osteomalacia, unspecified
269.0
Deficiency of vitamin K
270.2
Other disturbances of aromatic amino acid metabolism
270.9
Unspecified disorder of amino acid metabolism
271.0
Glycogenosis
272.0
Pure hypercholesterolemia
272.1
Pure hyperglyceridemia
272.2
Mixed hyperlipidemia
272.4
Other and unspecified hyperlipidemia
272.7
Lipidoses
272.9
Unspecified disorder of lipoid metabolism
273.4
Alpha 1 antitrypsin deficiency
275.01
Hereditary hemochromatosis
275.02
Hemochromatosis due to repeated red blood cell transfusions
275.03
Other hemochromatosis
275.09
Other disorders of iron metabolism
275.1
Disorders of copper metabolism
57
GGT (NCD)
GAMMA GLUTAMYLTRANSFERASE (GGT)
National Coverage Decision November 25, 2002
275.2
275.3
275.40-275.49
275.5
277.1
277.30-277.31, 277.39
277.4
277.6
282.60-282.69
286.6
286.7
289.4
289.52
291.0-291.9
303.00-303.03
303.90-303.93
304.00-304.93
305.00-305.93
357.5
359.21-359.29
452
453.0-453.9
456.0-456.21
555.0-555.9
556.0-556.9
557.0
558.1-558.9
560.0-560.2
560.3
560.31
560.32
560.39
560.81-560.89, 560.9
562.01
562.03
562.11
562.13
567.0-567.9
569.83
569.87
570
571.0-571.9
572.0-572.8
573.0-573.9
574.00-574.91
575.0-575.9
576.0-576.9
581.0-581.9
582.0-582.9
583.0-583.9
584.5-584.9
585.6
Disorders of magnesium metabolism
Disorders of phosphorus metabolism
Disorders of calcium metabolism
Hungry bone syndrome
Disorders of porphyrin metabolism
Amyloidosis
Disorders of bilirubin excretion
Other deficiencies of circulating enzymes
Sickle cell anemia
Defibrination syndrome
Acquired coagulation factor deficiency
Hypersplenism
Splenic sequestration
Alcoholic psychoses
Acute alcoholic intoxication
Other and unspecified alcohol dependence
Drug dependence
Non-dependent abuse of drugs
Alcoholic polyneuropathy
Myotonic disorders
Portal vein thrombosis
Other vein embolism and thrombosis
Esophageal varices
Regional enteritis
Ulcerative colitis
Acute vascular insufficiency of intestine
Other noninfectious gastroenteritis and colitis
Intestinal obstruction: intussusceptions, paralytic ileus, volvulus
Impaction of intestine, unspecified
Gallstone ileus
Fecal impaction
Other impaction of intestine
Other and unspecified intestinal obstruction
Diverticulitis of small intestine (without mention of hemorrhage)
Diverticulitis of small intestine with hemorrhage
Diverticulitis of colon (without mention of hemorrhage)
Diverticulitis of colon with hemorrhage
Peritonitis
Perforation of intestine
Vomiting of fecal matter
Acute and subacute necrosis of liver
Chronic liver disease and cirrhosis
Liver abscess and sequelae of chronic liver disease
Other disorders of liver
Cholelithiasis
Other disorders of gallbladder
Other disorders of biliary tract
Nephrotic syndrome
Chronic glomerulonephritis
Nephritis and nephropathy not specified as acute or chronic
Acute renal failure
Chronic renal failure
58
GGT (NCD)
GAMMA GLUTAMYLTRANSFERASE (GGT)
National Coverage Decision November 25, 2002
586
587
588.0-588.9
590.00-590.9
642.50-642.54
646.70,646.71,646.73
782.4
789.1
790.4
790.5
Renal failure, unspecified
Renal sclerosis, unspecified
Disorders resulting from impaired renal function
Infections of kidney
Severe pre-eclampsia
Liver disorders in pregnancy
Jaundice, unspecified, not of newborn
Hepatomegaly
Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase
Other nonspecific abnormal serum enzyme levels
960.00-969.09
969.70-969.79
969.8, 969.9
970.0-970.1
970.81
970.89
970.9
971.0-971.3, 971.9
972.0-972.9
973.0-973.6, 973.8,
973.9
974.0-974.7
975.0-975.8
Poisoning by antidepressants
Poisoning by psychostimulants
Poisoning by other specified and unspecified psychotropic agents
Poisoning by analeptics and opiate antagonists
Poisoning by cocaine
Poisoning by other central nervous system stimulants
Poisoning by unspecified central nervous system stimulants
Poisoning by drugs primarily affecting the autonomic nervous system
Poisoning by agents primarily affecting the cardiovascular system
Poisoning by agents primarily affecting the GI system
976.0-976.9
977.0-977.4, 977.8,
977.9
978.0-978.6, 978.8,
978.9
979.0-979.7
979.9
980.0-989.89
V42.7
V58.61-V58.69
V67.1
V67.2
V67.51
Reviewed:
Poisoning by water, mineral, and uric acid metabolism drugs
Poisoning by agents primarily acting on the smooth and skeletal muscles and
respiratory system
Poisoning by agents primarily affecting skin and mucous membrane,
ophthalmological, otorhinolaryngological, and dental drugs
Poisoning by other and unspecified drugs, and medicinal substances
Poisoning by bacterial vaccines
Poisoning by other vaccines and biological substances
Poisoning by drugs, medicinal, and biological substances
Toxic effects of substances chiefly nonmedicinal as to source
Organ replaced by transplant, liver
Long Term (current) drug use
Follow up examination, radiotherapy
Follow up examination, chemotherapy
Follow up examination after completed treatment with high-risk medications,
not elsewhere classified
April 2013
59
GGT (NCD)
GLYCATED HEMOGLOBIN AND GLYCATED PROTEIN
National Coverage Decision November 25, 2002
CPT: 82985
CPT: 83036
Glycated protein
Hemoglobin; Glycated
Frequency Limitation: This test is only deemed medically necessary every 3 months.
211.7
249.00-249.91
250.00-250.93*
251.0
251.1
251.2
251.3
251.4
251.8
251.9
258.0-258.9
271.4
275.01
275.02
275.03
275.09
577.1
579.3
648.00*
648.03*
648.04*
648.80
648.83
648.84
790.21
790.22
790.29
790.6
962.3
V12.21
V12.29
V58.67
V58.69
Benign neoplasm of islets of Langerhans
Secondary Diabetes Mellitus, with or without various manifestations
Diabetes mellitus & various related codes
Hypoglycemic coma
Other specified hypoglycemia
Hypoglycemia unspecified
Post-surgical hypoinsulinemia
Abnormality of secretion of glucagon
Other specified disorders of pancreatic internal secretion
Unspecified disorder of pancreatic internal secretion
Polyglandular dysfunction
Renal glycosuria
Hereditary hemochromatosis
Hemochromatosis due to repeated red blood cell transfusions
Other hemochromatosis
Other disorders of iron metabolism
Chronic pancreatitis
Other and unspecified postsurgical nonabsorption
Diabetes mellitus complicating pregnancy, childbirth or the puerperium,
unspecified as to episode of care or not applicable
Diabetes mellitus complicating pregnancy, Childbirth or the puerperium,
antepartum condition or complication
Diabetes mellitus complicating pregnancy, childbirth or the puerperium,
postpartum condition or complication
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, unspecified as to episode of care or not applicable
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, antepartum condition or complication
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, postpartum condition or complication
Impaired fasting glucose
Impaired glucose tolerance test
Other abnormal glucose (hyperglycemia)
Other abnormal blood chemistry
Poisoning by insulin and antidiabetic agents
Personal history of gestational diabetes
Personal history of other endocrine, metabolic, and immunity disorders
Long-term use of insulin
Long-term use of other medication
60
GLHGB (NCD)
GLYCATED HEMOGLOBIN AND GLYCATED PROTEIN
National Coverage Decision November 25, 2002
* Per Medicare, www.cms.gov, it is not considered reasonable and necessary to perform glycated
hemoglobin tests more often than every three months on a controlled diabetic patient to determine
whether the patient's metabolic control has been on average within the target range. It is not
considered reasonable and necessary for these tests to be performed more frequently than once a
month for diabetic pregnant women. Testing for uncontrolled type one or two diabetes mellitus may
require testing more than four times a year. Refer to CMS guidelines for the clinical basis for those
situations in which testing more frequently than four times per annum is indicated. Medical
necessity documentation must support such testing in excess of the above guidelines.
Reviewed:
April 2013
61
GLHGB (NCD)
GLUCOSE TESTING (BLOOD)
National Coverage Decision November 25, 2002
CPT: 82947
CPT: 82948
CPT: 82962
Glucose; quantitative, blood (except reagent strip)
Glucose; blood, reagent strip
Glucose, blood by glucose monitoring device(s) cleared by the FDA
specifically for home use
Frequency Limitation: See "Frequency Test List" for specifics.
011.00-011.96
038.0-038.9
112.1
112.3
118
157.4
158.0
211.7
242.00-242.91
249.00-249.91
250.00-250.93
251.0-251.9
253.0-253.9
255.0
263.0-263.9
271.0-271.9
272.0-272.4
275.01
275.02
275.03
275.09
276.0
276.1
276.2
276.3
276.4
276.50
276.51
276.52
276.61
276.69
276.7
276.8
276.9
278.3
293.0
294.9
298.9
300.9
310.1
331.83
337.9
345.10-345.11
348.31
355.9
Tuberculosis
Septicemia
Recurrent vaginal candidiasis
Interdigital candidiasis
Opportunistic mycoses
Malignant neoplasm of Islets of Langerhans
Malignant neoplasm of retroperitoneum
Benign neoplasm of Islets of Langerhans
Thyrotoxicosis
Secondary Diabetes Mellitus, with or without various manifestations
Diabetes mellitus
Disorders of pancreatic internal secretion
Disorders of the pituitary gland
Cushing syndrome
Malnutrition
Disorders of carbohyrdate transport and metabolism
Disorders of lipoid metabolism
Hereditary hemochromatosis
Hemochromatosis due to repeated red blood cell transfusions
Other hemochromatosis
Other disorders of iron metabolism
Hyperosmolality and/or hypernatremia
Hyposmolality and/or hyponatremia
Acidosis
Alkalosis
Mixed Aacid-base balance disorder
Volume depletion, unspecified
Dehydration
Hypovolemia
Transfusion associated circulatory overload
Other fluid overload
Hyperpotassemia
Hypopotassemia
Electrolyte and fluid disorders not elsewhere classified
Hypercarotinemia
Acute delirium
Unspecified organic brain syndrome
Unspecified psychosis
Unspecified neurotic disorder
Organic personality syndrome
Mild cognitive impairment, so stated
Autonomic nervous system neuropathy
Generalized convulsive epilepsy
Encephalopathy, unspecified
Neuropathy, not otherwise specified
62
GLUCOSE (NCD)
GLUCOSE TESTING (BLOOD)
National Coverage Decision November 25, 2002
356.9
357.9
362.10
362.18
362.29
362.50-362.57
362.60-362.66
362.81-382.89
362.9
365.04
365.32
366.00-366.09
366.10-366.19
367.1
368.8
373.00
377.24
377.9
378.50-378.55
379.45
410.00-410.92
414.00-414.19
414.3
414.4
425.9
440.23
440.24
440.9
458.0
462
466.0
480.0-486
490
491.0-491.9
527.7
528.00, 528.09
535.50-535.51
536.8
571.8
572.0-572.8
574.50-574.51
575.0-575.12
576.1
577.0
577.1
577.8
590.00-590.9
595.9
596.4
596.53
599.0
607.84
Unspecified hereditary and idiopathic peripheral neuropathy
Unspecified inflammatory and toxic neuropathy
Background retinopathy
Retinal vasculitis
Nondiabetic proliferative retinopathy
Degeneration of macular posterior pole
Peripheral retinal degeneration
Other retinal disorders
Unspecified retinal disorders
Borderline glaucoma, ocular hypertension
Corticosteroid-induced glaucoma residual
Presenile cataract
Senile cataract
Acute myopia
Other specified visual disturbance
Blepharitis
Pseudopapilledema
Unspecified disorder of optic nerve and visual pathways
Paralytic strabismus
Argyll-Robertson pupils
Acute myocardial infarctions
Coronary atherosclerosis and aneurysm of heart
Coronary atherosclerosis due to lipid rich plaque
Coronary atherosclerosis due to calcified coronary lesion
Secondary cardiomyopathy, unspecified
Arteriosclerosis of extremities with ulceration
Arteriosclerosis of extremities with gangrene
Arteriosclerosis, not otherwise specified
Postural hypotension
Acute pharyngitis
Acute bronchitis
Pneumonia
Recurrent bronchitis, not specified as acute or chronic
Chronic bronchitis
Disturbance of slaivary secretion (drymouth)
Stomatitis
Gastritis
Dyspepsia
Other chronic nonalcoholic liver disease
Liver abscess and sequelae of chronic liver disease
Choledocholithiasis
Cholecystitis
Cholangitis
Acute pancreatitis
Chronic pancreatitis
Pancreatic multiple calculi
Infections of the kidney
Recurrent cystitis
Bladder atony
Bladder paresis
Urinary tract infection, recurrent
Impotence of organic origin
63
GLUCOSE (NCD)
GLUCOSE TESTING (BLOOD)
National Coverage Decision November 25, 2002
608.89
616.10
626.0
626.4
628.9
648.00
648.03
648.04
648.80
648.83
648.84
649.20-649.24
656.60-656.63
657.00-657.03
680.0-680.9
686.00-686.9
698.0
698.1
704.1
705.0
707.00-707.9
709.3
729.1
730.07
730.17
730.27
780.01
780.02
780.09
780.2
780.31
780.32
780.39
780.4
780.71-780.79
780.8
781.0
782.0
783.1
783.21
783.5
783.6
785.0
785.4
786.01
Other disorders male genital organs
Vulvovaginitis
Amenorrhea
Irregular menses
Infertility - female
Diabetes mellitus complicating pregnancy, childbirth or the puerperium,
unspecified as to episode of care or not applicable
Diabetes mellitus complicating pregnancy, childbirth or the puerperium,
antipartum condition or complication
Diabetes mellitus complicating pregnancy, childbirth or the puerperium,
postpartum condition or complication
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, unspecified as to episode of care or not applicable
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, antepartum condition or complication
Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, postpartum condition or complication
Bariatric surgery status complicating pregnancy, childbirth, or the
puerperium, unspecified as to episode of care or not applicable
Fetal problems affecting management of mother - large for-date of fetus
Polyhydramnios
Carbunde and furuncle
Infections of skin and subcutaneous tissue
Pruritus ani
Pruritus of genital organs
Hirsutism
Anhidrosis
Chronic ulcer of skin
Degenerative skin disorders
Myalgia
Acute osteomyelitis of the ankle and foot
Chronic osteomyelitis of ankle and foot
Unspecified osteomyelitis of ankle and foot
Coma
Transient alteration of awareness
Alteration of consciousness, other
Syncope and collapse
Febrile convulsions
Complex febrile convulsions
Seizures, not otherwise specified
Dizziness and giddiness
Malaise and fatigue
Hyperhidrosis
Abnormal involuntary movements
Loss of vibratory sensation
Abnormal weight gain
Abnormal loss of weight
Polydipsia
Polyphagia
Tachycardia
Gangrene
Hyperventilation
64
GLUCOSE (NCD)
GLUCOSE TESTING (BLOOD)
National Coverage Decision November 25, 2002
786.09
786.50
787.6
787.61
787.62
787.63
787.91
788.41-788.43
789.1
790.21-790.29
790.6
791.0
791.5
796.1
799.4
* V23.0-V23.9
V58.63-V58.65
V58.67
V58.69
V67.2
V67.51
Dyspnea
Chest pain, unspecified
Full incontinence of feces
Incomplete defecation
Fecal smearing
Fecal urgency
Diarrhea
Frequency of urination and polyuria
Hepatomegaly
Abnormal glucose tolerance test
Other abnormal blood chemistry (hyperglycemia)
Proteinuria
Glycosuria
Abnormal reflex
Cachexia
Supervison of high risk pregnancy
Long-term (current) use of antiplatelet/antithrombotic
Long-term use of insulin
Long term current use of other medication
Follow-up examination, following chemotherapy
Follow up examination with high-risk medication not elsewhere classified
V77.1 **
Screening for diabetes mellitus. **This screening allowed once a year with
this code. If additional Glucose tests are performed, they must be diagnostic
or must have an ABN for frequency. Covered for CPT code 82947 only.
* V22.0-V23.9
OB Patients Only
Reviewed:
April 2013
65
GLUCOSE (NCD)
HCG QUANTITATIVE
National Coverage Decision November 25, 2002
CPT: 84702
HCG Quantitative; (Human Chorionic Gonadotropin)
158.0
158.8
164.2
164.3
164.8
640.00-640.03
642.30-642.34
Malignant neoplasm of retroperitoneum
Malignant neoplasm of specified parts of peritoneum
Malignant neoplasm of anterior mediastinum
Malignant neoplasm of posterior mediastinum
Malignant neoplasm, other (includes malignant neoplasm of contiguous
overlapping sites of thymus, heart, and mediastinum whose point of origin
cannot be determined
Malignant neoplasm of mediastinum, part specified
Malignant neoplasm of placenta
Malignant neoplasm of ovary
Other specified sites of uterine adnexa
Malignant neoplasm of undescended testis
Malignant neoplasm of other and unspecified testis
Malignant neoplasm of pineal gland
Secondary malignant neoplasm of mediastinum
Secondary malignant neoplasm of ovary
Secondary malignant neoplasm of ovary
Secondary malignant neoplasm of other genital organs
Neoplasm of uncertain behavior, placenta
Neoplasm related pain (acute)(chronic)
Vaginal bleeding
Pelvic pain
Hydatidiform mole
Inappropriate change in quantitative human chorionic gonadotropin (hCG) in
early pregnancy
Other abnormal products of conception
Missed abortion
Unspecified ectopic pregnancy
Spontaneous abortion, unspecified, complicated by genital tract and pelvic
infection
Threatened abortion, unspecified as to episode of care
Transient hypertension of pregnancy, unspecified as to episode of care
642.40-642.74
Mild or unspecified pre-eclampsia, unspecified as to episode of care
642.90-642.94
Unspecified hypertension complicating pregnancy, childbirth, or the
puerperium, unspecified as to episode of care
Other abnormal tumor markers
Personal history of malignant neoplasm, other gastrointestinal sites
164.9
181
183.0
183.8
186.0
186.9
194.4
197.1
197.6
198.6
198.82
236.1
338.3
623.8
625.9
630
631.0
631.8
632
633.90-633.91
634.00-634.02
795.89
V10.09
V10.29
V10.43
V10.47
V22.0-V22.1
Personal history of malignant neoplasm of other respiratory and intrathoracic
organs
Personal history of malignant neoplasm, ovary
Personal history of malignant neoplasm, testis
Normal pregnancy
Reviewed:
April 2013
66
HCG QUANT (NCD)
HEPATITIS PANEL, ACUTE
National Coverage Decision November 25, 2002
CPT: 80074
Hepatitis Panel, Acute
070.0-070.9
456.0-456.21
570
571.5
572.0-572.8
573.3
573.5
780.31-780.32
780.33
780.71
780.72
780.79
782.4
783.0-783.6
784.69
787.01-787.03
787.04
789.00-789.09
789.1
789.61
789.7
790.4
794.8
996.82
V72.85
Viral hepatitis
Esophageal varices with or without mention of bleeding
Acute and subacute necrosis of liver
Cirrhosis of liver without mention of alcohol
Liver abscess and sequelae of chronic liver disease
Hepatitis, unspecified
Hepatopulmonary syndrome
Febrile convulsions
Post traumatic seizures
Chronic fatigue syndrome
Functional quadriplegia
Other malaise and fatigue
Jaundice, unspecified, not of newborn
Symptoms concerning nutrition, metabolism, and development
Other symbolic dysfunction
Nausea and vomiting
Bilious emesis
Abdominal pain
Hepatomegaly
Localized abdominal tenderness (RUQ)
Colic
Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase
Non-specific abnormal results of function
Complication of transplanted organ, liver
Liver transplant recipient evaluation
Reviewed:
April 2013
67
HEPATITIS PANEL, ACUTE (NCD)
HUMAN IMMUNODEFICIENCY VIRUS TESTING (Diagnosis)
National Coverage Decision November 25, 2002
CPT: 86689
CPT: 86701
CPT: 86702
CPT: 86703
CPT: 87390
CPT: 87391
CPT: 87534
CPT: 87535
CPT: 87537
CPT: 87538
003.1
007.2
007.4
007.8
010.00-010.96
011.00-011.96
012.00-012.86
013.00-013.96
014.00-014.86
015.00-015.96
016.00-016.96
017.00-017.96
018.00-018.96
027.0
031.0-031.9
038.2
038.43
039.0-039.9
041.7
042
046.3
049.0-049.9
052.0-052.8
053.0-053.9
054.0-054.9
055.0-055.8
070.20-070.23
070.30-070.33
070.41
070.42
070.44
Qualitative or semiquantitative immunoassays performed by multiple step
methods; HTLV or HIV antibody, confirmatory test (for example, Western Blot)
Qualitative or semiquantitative immunoassays performed by multiple step
methods; HIV-1
Qualitative or semiquantitative immunoassays performed by multiple step
methods; HIV-2
Qualitative or semiquantitative immunoassays performed by multiple step
methods; HIV-1 and HIV-2, single assay
Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple step method; HIV-1
Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple step method; HIV-2
Infectious agent antigen by nucleic acid (DNA or RNA); HIV-1, direct probe
technique
Infectious agent antigen by nucleic acid (DNA or RNA); HIV-1, amplified probe
technique
Infectious agent antigen by nucleic acid (DNA or RNA); HIV-2, direct probe
technique
Infectious agent antigen by nucleic acid (DNA or RNA); HIV-2, amplified probe
technique
Salmonella septicemia
Coccidiosis (Isoporiasis)
Cryptosporidiosis
Other specified protozoal intestinal diseases
Primary tuberculous infection
Pulmonary tuberculosis
Other respiratory tuberculosis
Tuberculosis of meninges and central nervous system
Tuberculosis of intestines, peritoneum and mesenteric glands
Tuberculosis of bones and joints
Tuberculosis of genitourinary system
Tuberculosis of other organs
Miliary tuberculosis
Listeriosis
Diseases due to other mycobacteria
Pneumococcal septicemia
Septicemia (Pseudomonas)
Actinomycotic infections (includes Nocardia)
Pseudomonas infection
HIV disease (Acute retroviral syndrome, AIDS-related complex)
Progressive multifocal leukoencephalopathy
Other non-arthropod-borne viral diseases of central nervous system
Chickenpox (with complication)
Herpes zoster
Herpes simplex
Measles (with complication)
Viral hepatitis B with hepatic coma
Viral hepatitis B without mention of hepatic coma
Acute or unspecified hepatitis C with hepatic coma
Hepatitis delta without mention of active hepatitis B disease with hepatic
Chronic hepatitis C with hepatic coma
68
HIV DIAGNOSIS (NCD)
HUMAN IMMUNODEFICIENCY VIRUS TESTING (Diagnosis)
National Coverage Decision November 25, 2002
070.49
070.51
070.52
070.54
070.59
070.6
070.70
070.71
070.9
078.0
078.10-078.19
078.3
078.5
078.88
079.50
079.51
079.52
079.53
079.59
079.88
079.98
085.0-085.9
088.0
090.0-090.9
091.0-091.9
092.0-092.9
093.0-093.9
094.0-094.9
095.0-095.9
096
097.0-097.9
098.0-098.89
099.0
099.1
099.2
099.3
099.40-099.49
099.50-099.59
099.8
099.9
110.1
111.0
112.0-112.9
114.0-114.9
115.00-115.99
116.0-116.2
117.3
117.5
118
127.2
130.0-130.9
Other specified viral hepatitis with hepatic coma
Acute or unspecified hepatitis C without hepatic coma
Hepatitis delta without mention of active hepatitis B disease without hepatic
coma
Chronic hepatitis C without hepatic coma
Other specified viral hepatitis without hepatic coma
Unspecified viral hepatitis with hepatic coma
Viral hepatitis
Viral hepatitis
Unspecified viral hepatitis without hepatic coma
Molluscum contagiosum
Viral warts
Cat-scratch disease
Cytomegaloviral disease
Other specified diseases due to Chlamydiae
Retrovirus unspecified
HTLV-I
HTLV-II
Human immunodeficiency virus, type 2
Other specified Retrovirus
Other specified chlamydial infection
Unspecified chlamydial infection
Leishmaniasis
Bartonellosis
Congenital syphilis
Early syphilis symptomatic
Early syphilis, latent
Cardiovascular syphilis
Neurosyphilis
Other forms of late syphilis, with symptoms
Late syphilis, latent
Other and unspecified syphilis
Gonococcal infections
Chancroid
Lymphogranuloma venereum
Granuloma inguinale
Reiter's disease
Other nongonococcal urethritis
Other venereal diseases due to Chlamydia trachomatis
Other specified venereal disease
Venereal Disease unspecified
Dermatophytosis of nail
Ityriasis versicolor
Candidiasis
Coccidioidmycosis
Histoplasmosis
Blastomycotic infection
Aspergillosis
Cryptococcosis
Opportunistic mycoses
Strongyloidiasis
Toxoplasmosis
69
HIV DIAGNOSIS (NCD)
HUMAN IMMUNODEFICIENCY VIRUS TESTING (Diagnosis)
National Coverage Decision November 25, 2002
131.01
132.2
133.0
136.21-136.29
136.3
136.8
176.0-176.9
180.0-180.9
200.20-200.28
200.80-200.88
201.00-201.98
263.0
263.1
263.9
280.0-280.9
285.9
287.30-278.39
288.00-288.09
288.4
288.50-288.69
288.8
289.53
294.8
310.1
322.2
331.19
331.83
336.9
348.30
348.39
354.0-354.9
356.8
363.20
425.4
473.0-473.9
481-482.9
484.1
486
512.81
512.82
512.83
516.8
528.2
528.6
530.20
530.21
530.85
583.9
588.81, 588.89
647.60-647.64
682.0-682.9
Trichomonal vulvovaginitis
Phthirus pubis
Scabies
Specific infections by free living amebae
Pneumocystosis
Other specified infectious and parasitic disease (for example,
microsporidiosis)
Kaposi's sarcoma
Malignant neoplasm of cervix uteri
Burkitt's tumor or lymphoma
Lymphosarcoma, other named variants
Hodgkin's disease
Malnutrition of moderate degree
Malnutrition of mild degree
Unspecified protein-calorie malnutrition
Iron deficiency anemias
Anemia, unspecified
Primary thrombocytopenia
Agranulocytosis
Hemophagocytic syndromes
Leukocytopenia
Other specified disease of white blood cells
Neutropenic splenomegaly
Other persistent mental disorders due to conditions classified elsewhere
Personality change due to conditions classified elsewhere
Chronic meningitis
Other frontotemporal dementia
Mild cognitive impairment, so stated
Unspecified disease of spinal cord
Encephalopathy unspecified
Other encephalopathy
Mononeuritis of upper limbs and mononeuritis multiplex
Other specified idiopathic peripheral neuropathy
Chorioretinitis, unspecified
Other primary cardiomyopathies
Chronic sinusitis
Pneumococcal pneumonia
Pneumonia in cytomegalic inclusion disease
Pneumonia, organism unspecified
Primary spontaneous pneumothorax
Secondary spontaneous pneumothorax
Chronic pneumothorax
Other specified alveolar and parietoalveolar pneumonopathies
Oral aphthae
Leukoplakia of oral mucosa
Ulcer of esophagus
Ulcer of esophagus with bleeding
Barrett's esophagus
Nephropathy with unspecified pathological lesion in kidney
Other specified disorders resulting from impaired renal function
Other viral diseases complicating pregnancy (use for HIV I and II)
Other cellulitis and abscess
70
HIV DIAGNOSIS (NCD)
HUMAN IMMUNODEFICIENCY VIRUS TESTING (Diagnosis)
National Coverage Decision November 25, 2002
690.10-690.18
696.1
698.3
704.8
706.0-706.9
780.60-780.65
780.66
780.79
783.21
783.40
785.6
786.00
786.05
786.2
786.30
786.31
786.39
786.4
787.91
795.71
799.4
V01.71, V01.79
V71.5
Seborrheic dermatitis
Other psoriasis
Lichenification and lichen simplex chronicus
Other specified diseases of hair and hair follicles
Diseases of sebaceous glands
Fever and other physiologic disturbances of temperature regulation
Febrile nonhemolytic transfusion reaction
Other malaise and fatigue
Abnormal loss of weight
Lack of expected normal physiological development
Enlargement of lymph nodes
Respiratory abnormality, unspecified
Shortness of breath
Cough
Hemoptysis, unspecified
Acute idiopathic pulmonary hemorrhage in infants (AIPHI)
Other hemoptysis
Abnormal sputum
Diarrhea
Nonspecific serologic evidence of human immunodeficiency virus
Wasting disease
Contact with or exposure to communicable diseases, other viral diseases
Rape
Reviewed:
April 2013
71
HIV DIAGNOSIS (NCD)
HUMAN IMMUNODEFICIENCY VIRUS TESTING (Prognosis Including Monitoring)
National Coverage Decision November 25, 2002
CPT: 87536
Infectious agent detection by nucleic acid (DNA or RNA); HIV-1 quantification
CPT: 87539
Infectious agent detection by nucleic acid (DNA or RNA); HIV-2 quantification
042
079.53
647.60-647.64
795.71
Human immunodeficiency virus (HIV) disease
Human immunodeficiency virus, type 2 [HIV-2]
Other viral diseases complicating pregnancy (including HIV-I and II)
Non-specific serologic evidence of human immunodeficiency virus (HIV)
V08
Asymptomatic human immunodeficiency virus (HIV) infection status
Reviewed:
April 2013
72
HIV (NCD)
IRON STUDIES; SERUM
National Coverage Decision November 25, 2002
CPT:
CPT:
CPT:
CPT:
82728
83540
83550
84466
002.0-002.9
003.0-003.9
006.0-006.9
007.0-007.9
008.00-008.8
009.0-009.3
011.50-011.56
014.00-014.86
015.00-015.96
016.00-016.06
016.10-016.16
016.20-016.26
016.30-016.36
042
070.0-070.9
140.0-149.9
150.0-159.9
160.0-165.9
170.0-176.9
179-189.9
190.0-199.2
200.00-208.92
209.00-209.03
209.10-209.17
209.20-209.29
209.30
209.31-209.36
209.40-209.43
209.50-209.57
209.60-209.69
209.70
209.71
209.72
209.73
209.74
209.75
209.79
210.0-229.9
230.0-234.9
235.0-235.9
236.0-236.99
237.0-237.72
237.73
237.79
237.9
Ferritin
Iron
Iron Binding capacity
Transferrin
Typhoid and paratyphoid fevers
Other salmonella infections
Amebiasis
Other protozoal intestinal diseases
Intestinal infections due to other organisms
Ill-defined intestinal infections
Tuberculous bronchiectasis
Tuberculosis of intestines, peritoneum, and mesenteric glands
Tuberculosis of bones and joints
Tuberculosis of kidney
Tuberculosis of bladder
Tuberculosis of ureter
Tuberculosis of other urinary organs
Human Immunodeficiency virus (HIV) disease
Viral hepatitis
Malignant neoplasm of lip oral cavity and pharynx
Malignant neoplasm of digestive organs and peritoneum
Malignant neoplasm of respiratory and intrathoracic organs
Malignant neoplasm of bone, connective tissue, skin and breast
Malignant neoplasm of genitourinary organs
Malignant neoplasm without specification of site
Malignant neoplasm of lymphatic and hematopoietic tissue
Benign carcinoid tumors of the small intestine
Benign carcinoid tumors of the appendix, large intestine and rectum
Benign carcinoid tumors of other and unspecified sites
Malignant poorly differentiated neuroendocrine carcinoma, any site
Merkel cell carcinoma
Malignant carcinoid tumors of the small intestine
Malignant carcinoid tumors of the appendix, large intestine and rectum
Malignant carcinoid tumors of other and unspecified sites
Secondary neuroendocrine tumor, unspecified site
Secondary neuroendocrine tumor of distant lymph nodes
Secondary neuroendocrine tumor of liver
Secondary neuroendocrine tumor of bone
Secondary neuroendocrine tumor of peritoneum
Secondary Merkel cell carcinoma
Secondary neuroendocrine tumor of other sites
Benign neoplasms
Carcinoma in situ
Neoplasms of uncertain behavior of digestive and respiratory systems
Neoplasms of uncertain behavior of genitourinary organs
Neoplasms of uncertain behavior of endocrine glands and nervous system
Schwannomatosis
Other neurofibromatosis
Other and uncertain parts of the nervous system
73
IRON STUDIES (NCD)
IRON STUDIES; SERUM
National Coverage Decision November 25, 2002
238.0-238.6
238.71-238.76
238.77
238.79, 238.8, 238.9
239.0-239.7
239.81
239.89
239.9
249.00-249.91
250.00-250.93
253.2
253.7
253.8
256.31-256.39
257.2
260
261
262
263.0-263.9
275.01
275.02
275.03
275.09
277.1
280.0-280.9
281.0-281.9
282.40-282.49
282.60-282.63
282.64
282.68
282.69
285.0
285.1
285.21
285.3
285.9
286.0-286.9
287.0-287.39
287.41
287.49
287.5-287.9
289.52
306.4
307.1
307.50-307.59
403.01
403.11
Neoplasms of uncertain behavior of other and unspecified sites and tissues
Neoplasms of other lymphatic and hematopoietic tissues
Post-transplant lymphoproliferative disorder (PTLD)
Neoplasms of uncertain behavior
Neoplasms of unspecified nature
Neoplasms of unspecified nature, retina and choroid
Neoplasms of unspecified nature, other specified sites
Neoplasms of unspecified nature, site unspecified
Secondary Diabetes Mellitus, with or without various manifestations
Diabetes mellitus
Panhypopituitarism
Iatrogenic pituitary disorders
Other disorders of the pituitary and other syndromes of
diencephalohypophysial origin
Other ovarian failure
Other testicular hypofunction
Kwashiorkor
Nutritional marasmus
Other severe protein-calorie malnutrition
Other and unspecified protein-calorie malnutrition
Hereditary hemochromatosis
Hemochromatosis due to repeated red blood cell transfusions
Other hemochromatosis
Other disorders of iron metabolism
Disorders of porphyrin metabolism
Iron deficiency anemias
Other deficiency anemias
Thalassemias
Sickle cell anemia
Sickle-cell/Hb-C disease with crisis
Other sickle-cell disease without crisis
Sickle cell anemia, other
Sideroblastic anemia (includes hemochromatosis with refractory anemia)
Acute post-hemorrhagic anemia
Anemia in end-stage renal disease
Antineoplastic chemotherapy induced anemia
Anemia, unspecified
Coagulation defects ( congenital factor disorders)
Allergic purpura; qualitative platelet defects; other non-thrombocytopenic
purpuras; primary thrombocytopenia
Posttransfusion purpura
Other secondary thrombocytopenia
Thrombocytopenia, unspecified; other specified and unspecified hemorrhagic
conditions
Splenic sequestration
Physiological malfunction arising from mental factors, gastrointestinal
Anorexia nervosa
Other and unspecified disorders of eating
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
74
IRON STUDIES (NCD)
IRON STUDIES; SERUM
National Coverage Decision November 25, 2002
403.91
425.4
425.5
425.7
425.8
425.9
426.0-426.9
427.0-427.9
428.0-428.9
530.7
Hypertensive chronic kidney disease, unspecified, with chronic kidney
disease stage V or end stage renal disease
Hypertensive 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, 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
Hypertensive heart and chronic kidney disease, unspecified, without heart
failure and with chronic kidney disease stage V or end stage renal disease
Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and chronic kidney disease stage V or end stage renal disease
Other primary cardiomyopathies
Alcoholic cardiomyopathy
Nutritional and metabolic cardiomyopathy
Cardiomyopathy in other diseases classified elsewhere
Secondary cardiomyopathy, unspecified
Conduction disorders
Cardiac dysrhythmias
Heart Failure
Gastroesophageal laceration-hemorrhage syndrome
530.82
531.00-531.91
532.00-532.91
533.00-533.91
534.00-534.91
535.00-535.71
536.0-536.9
537.83
537.84
555.0-555.9
556.0-556.9
557.0
557.1
562.02
562.03
562.12
562.13
569.3
569.85
569.86
569.87
570
571.0-571.9
572.0-572.8
573.0-573.9
578.0-578.9
579.0-579.3
579.8-579.9
Esophageal hemorrhage
Gastric ulcer
Duodenal ulcer
Peptic ulcer, site unspecified
Gastrojejunal ulcer
Gastritis and duodenitis
Disorders of function of stomach
Angiodysplasia of stomach and duodenum with hemorrhage
Dielulafoy Lesion (Hemorrhagic) of stomach and duodenum
Regional enteritis
Ulcerative colitis
Acute vascular insufficiency of intestine
Chronic vascular insufficiency of intestine
Diverticulosis of small intestine with hemorrhage
Diverticulitis of small intestine with hemorrhage
Diverticulosis of colon with hemorrhage
Diverticulitis of colon with hemorrhage
Hemorrhage of rectum an anus
Angiodysplasia of intestine with hemorrhage
Dieulafoy lesion (Hemorrhagic) of intestine
Vomiting of fecal matter
Acute and subacute necrosis of liver
Chronic liver disease and cirrhosis
Liver abscess and sequelae of chronic liver disease
Other disorders of liver
Gastrointestinal hemorrhage
Intestinal malabsorption
Other specified and unspecified intestinal malabsorption
404.02
404.03
404.12
404.13
404.92
404.93
75
IRON STUDIES (NCD)
IRON STUDIES; SERUM
National Coverage Decision November 25, 2002
581.0-581.9
585.4-585.9
586
608.3
626.0-626.9
698.0-698.9
704.00-704.09
709.00-709.09
713.0
716.40-716.99
719.40-719.49
773.2
773.3
773.4
773.5
783.9
790.01-790.09
790.4
790.5
790.6
799.4
964.0
984.0-984.9
996.85
999.80
999.83
999.84
999.85
999.89
V08
V12.1
V12.3
V15.1
V15.21
V15.22
V15.29
V43.21-V43.22
V43.3
V43.4
V43.60
V56.0
V56.8
Nephrotic syndrome
Chronic renal failure
Renal failure, unspecified
Atrophy of testis
Disorders of menstruation and other abnormal bleeding from female genital
tract
Premenopausal menorrhagia
Postmenopausal bleeding
Other current conditions in the mother classifiable elsewhere, but
complicating pregnancy, childbirth , or puerperium: Anemia
Pruritus and related conditions
Alopecia
Dyschromia
Arthropathy associated with other endocrine and metabolic disorders
Other and unspecified arthropathies
Pain in joint
Hemolytic disease due to other and unspecified isoimmunization
Hydrops fetalis due to isoimmunization
Kernicterus due to isoimmunization
Late anemia due to isoimmunization
Other symptoms concerning nutrition, metabolism and development
Abnormality of red blood cells
Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase
Other nonspecific abnormal serum enzyme levels
Other abnormal blood chemistry
Cachexia
Poisoning by agents primarily affecting blood constituents, iron compounds
Toxic effect of lead and its compounds (including fumes)
Complications of transplanted organ, bone marrow
Transfusion reaction, unspecified
Hemolytic transfusion reaction, incompatibility unspecified
Acute hemolytic transfusion reaction, incompatibility unspecified
Delayed hemolytic transfusion reaction, incompatibility unspecified
Other transfusion reaction
Asymptomatic HIV infection
Personal history of nutritional deficiency
Personal history of diseases of blood and blood forming organs
Personal history of surgery to heart and great vessels
Personal history of undergoing in utero procedure during pregnancy
Personal history of undergoing in utero procedure while a fetus
Personal history of surgery of other major organs
Heart replaced by other means
Heart valve replaces by other means
Blood vessel replaced by other means
Unspecified joint replaced by other means
Extracorporeal dialysis
Other dialysis
Reviewed:
April 2013
627.0
627.1
648.20-648.24
76
IRON STUDIES (NCD)
LIPID PROFILE AND CHOLESTEROL TESTING
National Coverage Decision November 25, 2002
CPT:
CPT:
CPT:
CPT:
CPT:
80061
82465
83700
83701
83704
CPT: 83718
CPT: 83721
CPT: 84478
Lipid Panel
Cholesterol, serum or whole blood, total
Lipoprotein, blood; electophorectic
Lipoprotein, blood: high fractionation
Lipoprotein blood: quantitation of lipoprotein particle numbers and
lipoprotein particles subclasses
Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
Lipoprotein, direct measurement, LDL cholesterol
Triglycerides
Frequency Limitation: See "Frequency Test List" for specifics.
242.00-245.9
249.00-249.91
250.00-250.93
255.0
260
261
262
263.0
263.1
263.8
263.9
270.0
271.1
272.0
272.1
272.2
272.3
272.4
272.5
272.6
272.7
272.8
272.9
277.30-277.39
278.00
278.01
278.02
278.03
303.90-303.92
362.10-362.16
362.30-362.34
362.82
371.41
374.51
379.22
388.00
388.02
401.0, 401.1,401.9
402.00-402.91
403.00-403.91
Disorders of the thyroid gland with hormonal dysfunction
Secondary diabetes mellitus with renal manifestations
Diabetes mellitus
Cushing's syndrome
Kwashiorkor
Nutritional marasmus
Other severe, protein-calorie malnutrition
Malnutrition of moderate degree
Malnutrition of mild degree
Other protein-calorie malnutrition
Unspecified protein-calorie malnutrition
Disturbances of amino-acid transport
Galactosemia
Pure hypercholesterolemia
Hyperglyceridemia
Mixed hyperlipidemia (tuberous xanthoma)
Hyperchylomicronemia
Other and unspecified hyperlipidemia (unspecified xanthoma)
Lipoprotein deficiencies
Lipodystrophy
Lipidoses
Other disorders of lipoid metabolism
Unspecified disorders of lipoid metabolism
Amyloidosis
Obesity
Morbid obesity
Overweight
Obesity hypoventilation syndrome
Alcoholism
Other background retinopathy and retinal vascular change
Retinal vascular occlusion
Retinal exudates and deposits
Senile corneal changes
Xanthelasma
Crystalline deposits in vitreous
Degenerative and vascular disorder of ear, unspecified
Transient ischemic deafness
Essential hypertension
Hypertensive heart disease
Hypertensive renal disease
77
LIPID (NCD)
LIPID PROFILE AND CHOLESTEROL TESTING
National Coverage Decision November 25, 2002
404.00-404.93
405.01-405.99
410.00-410.92
411.0-411.1
411.81
411.89
412
413.0-413.1
413.9
414.00-414.03
414.04
414.05
414.06
414.07
414.10
414.11
414.12
414.19
414.3
414.4
414.8
414.9
428.0-428.9
429.2
429.9
431
433.00-433.91
434.00-434.91
435.0-435.9
437.0
437.1
437.5
438.0
438.13
438.14
438.9
440.0-440.9
441.00-441.9
442.0
442.1
442.2
444.01, 444.09,
444.1-444.9
557.1
571.8
571.9
573.5
573.8
573.9
577.0-577.9
579.3
579.8
Hypertensive heart and renal disease
Secondary hypertension
Acute myocardial infarction
Other acute and subacute forms of ischemic heart disease
Coronary occlusion without myocardial infarction
Other acute and subacute ischemic heart disease
Old myocardial infarction
Angina pectoris
Other and unspecified angina pectoris
Coronary atherosclerosis
Coronary atherosclerosis of artery bypass graft
Coronary athrscl-unspec graft
Coronary atherosclerosis of coronary artery of transplanted heart
Coronary atherosclerosis, of bypass graft (artery)(vein) of transplanted heart
Aneurysm, heart (wall)
Coronary vessel aneurysm
Dissection of coronary artery
Other aneurysm of heart
Coronary atherosclerosis due to lipid rich plaque
Coronary atherosclerosis due to calcified coronary lesion
Other specified forms of chronic ischemic heart disease
Chronic ischemic heart disease, unspecified
Heart failure
Heart disease, unspecified
Heart disease NOS
Intracerebral hemorrhage
Occlusion and stenosis of precerebral arteries
Occlusion of cerebral arteries
Transient cerebral ischemia
Cerebral atherosclerosis
Other generalized ischemic cerebrovascular disease
Moyamoya disease
Late effects of cerebrovascular disease
Late effects of cerebrovascular disease, dysarthria
Late effects of cerebrovascular disease, fluency disorder
Unspecified late effects of cerebrovascular disease
Arteriosclerosis
Aortic aneurysms
Upper extremity aneurysm
Renal artery aneurysm
Iliac artery aneurysm
Arterial embolism and thrombosis
Chronic vascular insufficiency of intestine
Other chronic non-alcoholic liver disease
Unspecified chronic liver disease without mention of alcohol
Hepatopulmonary syndrome
Other specified disorders of liver
Unspecified disorders of liver
Pancreatic disease
Other and unspecified postsurgical nonabsorption
Other specified intestinal malabsorption
78
LIPID (NCD)
LIPID PROFILE AND CHOLESTEROL TESTING
National Coverage Decision November 25, 2002
581.0-581.9
584.5
585.4-585.9
588.0
588.1
588.81, 588.89
588.9
607.84
646.70-646.71
646.73
Nephrotic syndrome
Acute renal failure with lesion of tubular necrosis
Chronic renal failure
Renal osteodystrophy
Nephrogenic diabetes insipidus
Other specified disorders resulting from impaired renal function
Unspecified disorder resulting from impaired renal function
Impotence of organic origin, penis disorder
Liver disorders in pregnancy
Liver and biliary tract disorders in pregnancy, antepartum condition or
complication
648.10-648.14
Thyroid dysfunction in pregnancy and the puerperium
696.0
Psoriatic Arthropathy
696.1
Other psoriasis
751.61
Biliary atresia
764.10-764.19
"Light-For-Dates" with signs of fetal malnutrition
786.50
Chest pain unspecified
786.51
Precordial pain
786.59
Chest pain, other
789.1
Hepatomegaly
790.4
Abnormal transaminase
790.5
Abnormal alkaline phosphatase
790.6
Other abnormal blood chemistry
793.4
Abnormal imaging study
987.9
Toxic effect of unspecified gas or vapor
996.81
Complication of transplanted organ, kidney
V42.0
Transplanted organ, kidney
V42.7
Organ Replacement by transplant, liver
V58.63-V58.64
Long-term (current) use of antiplatelet/antithrombotic
V58.69
Long-term (current) use of other medications
V81.0, V81.1, V81.2 ** Screening for other unspecified Cardiovascular conditions. ** This screening
is only allowed 1 every 5 years with these codes. If additional Lipids tests are
performed, they must be diagnostic or must have an ABN for frequency.
Covered for CPT codes 80061, 82465, 83718 and 84478 only.
Reviewed:
April 2013
79
LIPID (NCD)
BLOOD, OCCULT; FECES SCREENING
National Coverage Decision November 25, 2002
CPT: 82272
CPT: G0394
Blood occult peroxidase
Blood Occult Test (e.g., guaiac), feces, for single determination for colorectal
neoplasm (e.g., patient was provided three cards or single triple card for
consecutive collection)
Frequency Limitation: See "Frequency Test List" for specifics.
003.0
003.1
004.0-004.9
005.0-005.9
006.0-006.9
007.0-007.9
008.41-008.49
009.0-009.3
014.00-014.86
040.2
095.2
095.3
098.0
098.7
098.84
123.0-123.9
124
127.0-127.9
139.8
Salmonella gastroenteritis
Salmonella septicemia
Shigellosis
Other food poisoning (bacterial)
Amebiasis
Other protozoal intestinal diseases
Intestinal infections due to other specified bacteria
Ill-defined intestinal infections
Tuberculosis of intestines, peritoneum, and mesenteric glands
Whipple's disease
Syphilitic peritonitis
Syphilis of liver
Gonococcal infection, acute, lower genitourinary tract
Gonococcal Infection anus and rectum
Gonococcal endocarditis
Other cestode infection
Trichinosis
Other intestinal helminthiases
Late effects of other and unspecified infectious and parasitic diseases
150.0-157.9
159.0-159.9
Malignant neoplasm of digestive organisms
Malignant neoplasm of other and ill-defined sites within the digestive organs
and peritoneum
Kaposi's sarcoma, gastrointestinal sites
Secondary malignant neoplasm of intestines
Secondary malignant neoplasm of other digestive organs and spleen
Disseminated malignant neoplasm
Lymphoid leukemia
Leukemia (Myeloid, Monocytic, Other or Unspecified type)
Benign carcinoid tumors of the small intestine
Benign carcinoid tumors of the appendix, large intestine and rectum
Malignant carcinoid tumors of the small intestine
Malignant carcinoid tumors of the appendix, large intestine and rectum
Secondary neuroendocrine tumor, unspecified site
Secondary neuroendocrine tumor of distant lymph nodes
Secondary neuroendocrine tumor of liver
Secondary neuroendocrine tumor of bone
Secondary neuroendocrine tumor of peritoneum
Secondary Merkel cell carcinoma
Secondary neuroendocrine tumor of other sites
Benign neoplasm of other parts of digestive system
Hemangioma of intra-abdominal structures
Carcinoma in situ of digestive organs
Neoplasm of uncertain behavior of stomach, intestines and rectum
Neoplasm of uncertain behavior of other and unspecified digestive organs
176.3
197.4-197.5
197.8
199.0
204.00-204.92
205.00-208.92
209.00-209.03
209.10-209.17
209.40-209.43
209.50-209.57
209.70
209.71
209.72
209.73
209.74
209.75
209.79
211.0-211.9
228.04
230.2-230.9
235.2
235.5
80
OCCULT BLOOD (NCD)
BLOOD, OCCULT; FECES SCREENING
National Coverage Decision November 25, 2002
239.0
280.0-280.9
284.2
285.0-285.9
286.0-286.9
287.0-287.39
287.41
287.49
287.5-287.9
338.3
448.0
455.0-455.8
456.0-456.21
530.10-535.71
536.2
536.8-536.9
537.0-537.4
537.82-537.83
537.84
537.89
555.0-558.9
560.0-560.2
560.3
560.31
560.32
560.39
560.81-560.89, 560.9
562.10-562.13
564.00-564.9
565.0-565.1
569.0
569.1
569.3
569.41-569.49
569.82-569.83
569.84-569.85
569.86
569.87
571.0-571.9
577.0-577.9
578.0-578.9
579.0
579.8
596.1
617.5
780.71
780.72
780.79
783.0
Neoplasm of unspecified nature, digestive system
Iron deficiency anemias
Myelophthisis
Other and unspecified anemias
Coagulation defects
Allergic purpura; qualitative platelet defects; other non-thrombocytopenic
purpuras; primary thrombocytopenia
Posttransfusion purpura
Other secondary thrombocytopenia
Thrombocytopenia, unspecified; other specified and unspecified hemorrhagic
conditions
Neoplasm related pain (acute)(chronic)
Hereditary hemorrhagic telangiectasia
Hemorrhoids
Esophageal varices with or without mention of bleeding
Diseases of esophagus, stomach, and duodenum
Persistent vomiting
Dyspepsia and other specified and unspecified functional disorders of the
stomach
Other disorders of stomach and duodenum
Angiodysplasia of stomach and duodenum
Dieulatoy lesion (hemorrhagic) of stomach and duodenum
Other specified disorders of the stomach and duodenum
Non-infectious enteritis and colitis
Intestinal obstruction: intussusceptions, paralytic ileus, volvulus
Impaction of intestine, unspecified
Gallstone ileus
Fecal impaction
Other impaction of intestine
Other and unspecified intestinal obstruction
Diverticulosis/diverticulitis of colon
Functional digestive disorders, not elsewhere classified
Anal fissure
Anal and rectal polyp
Rectal prolapse
Hemorrhage of rectum and anus
Other specified disorders of rectum and anus
Ulceration and perforation of intestine
Angiodysplasia of intestine with or without mention of hemorrhage
Dieulafoy lesion (hemorrhagic) of intestine
Vomiting of fecal matter
Chronic liver disease and cirrhosis
Diseases of the pancreas
Gastrointestinal hemorrhage
Celiac disease
Other specified intestinal malabsorption
Intestinovesical fistula
Endometriosis of intestine
Chronic fatigue syndrome
Functional quadriplegia
Other malaise and fatigue
Anorexia
81
OCCULT BLOOD (NCD)
BLOOD, OCCULT; FECES SCREENING
National Coverage Decision November 25, 2002
783.21
787.01-787.03
787.04
787.1
787.20-787.29
787.7
787.91
787.99
789.00-789.09
789.30-789.39
789.40-789.49
789.51
789.59
789.60-789.69
789.7
790.92
792.1
793.6
794.8
863.0-863.90
863.91-863.95, 863.99
864.00-864.09
864.11-864.19
866.00-866.03
866.10-866.13
902.0-902.9
926.11-926.19
926.8
926.9
995.20
995.24
964.2
V10.00-V10.09
V12.00
V12.72
V58.61
V58.63-V58.66
V58.69
V67.51
V76.51 **
Reviewed:
Abnormal loss of weight
Nausea and vomiting
Bilious emesis
Heartburn
Dysphagia
Abnormal feces
Diarrhea
Other symptoms involving digestive system
Abdominal pain
Abdominal or pelvic swelling, mass, or lump
Abdominal rigidity
Malignant Ascites
Other Ascites
Abdominal tenderness
Colic
Abdominal coagulation profile
Nonspecific abnormal findings in stool contents
Nonspecific abnormal findings on radiological and other
Nonspecific abnormal results of function studies, liver
Injury to gastrointestinal tract
Injury to pancreas
Injury to liver without mention of open wound into cavity
Injury to liver with open wound into cavity
Injury to kidney without mention of open wound into cavity
Injury to kidney with open wound into cavity
Injury to blood vessels of abdomen and pelvis
Crushing injury of trunk, other specified sites
Crushing injury of trunk, multiple sites
Crushing injury of trunk, unspecified site
Unspecified adverse effect of unspecified drug, medicinal and biological
substance
Failed moderate sedation during procedure
Poisoning by agents primarily affecting blood constituents, anticoagulants
Personal history of malignant neoplasm, gastrointestinal tract
Personal history of unspecified infectious and parasitic disease
Personal history of colonic polyps
Long term (current) use of anticoagulants
Long-term (current) drug use
Long term (current) use of other medications
Following treatment with high risk medication, not elsewhere specified
Screening for malignant neoplasm of the colon. **This screening is only
allowed once every 365 days with this code. If additional Occult Blood tests
are performed they must be diagnostic or must have an ABN for frequency.
April 2013
82
OCCULT BLOOD (NCD)
PROSTATE SPECIFIC ANTIGEN (PSA)
National Coverage Decision November 25, 2002
CPT: 84153
Prostate Specific Antigen; Total
Frequency Limitation: See "Frequency Test List" for specifics.
185
188.5
196.5
196.6
196.8
198.5
198.82
233.4
236.5
239.5
596.0
599.60
599.69
599.70-599.72
600.00
600.01
600.10
600.11
600.21
601.9
602.9
788.20
788.21
788.30
788.41
788.43
788.62
788.63-788.65
790.93
793.6, 793.7
794.9
V10.46
V76.44 **
Reviewed:
Malignant neoplasm of prostate
Malignant neoplasm of bladder neck
Secondary malignant neoplasm, lymph nodes inguinal region and lower limb
Secondary malignant neoplasm, intrapelvic lymph nodes
Secondary malignant neoplasm, lymph nodes of multiple sites
Secondary malignant neoplasm, bone and bone marrow
Secondary malignant neoplasm, genital organs
Carcinoma in situ, prostate
Neoplasm of uncertain behavior of prostate
Neoplasm of unspecified nature, other genitourinary organs
Bladder neck obstruction
Urinary obstruction, unspecified
Urinary obstruction, not elsewhere classified
Hematuria
Hypertrophy (benign) of prostate without urinary obstruction and other lower
urinary tract (LUTS)
Benign prostate hypertrophy with urinary obstruction
Nodular prostate without urinary obstruction
Nodular prostate with urinary obstruction
Benign localized hyperplasia of prostate with urinary obstruction and other
lower urinary tract symptoms (LUTS)
Unspecified prostatitis
Unspecified disorder of prostate
Retention of urine, unspecified
Incomplete bladder emptying
Urinary incontinence, unspecified
Urinary frequency
Nocturia
Slowing of urinary stream
Urgency of urination
Elevated prostate specific antigen
Non-specific abnormal result of radiologic examination, evidence of
malignancy
Bone scan evidence of malignancy
Personal history of malignant neoplasm; prostate
Screening for malignant neoplasm of the prostate. **This screening is only
covered for men over 50 years of age once every 365 days with this code. If
additional PSA tests are performed they must be diagnostic or must have an
ABN for frequency.
April 2013
83
PSA (NCD)
PROTHROMBIN TIME
National Coverage Decision November 25, 2002
CPT: 85610
Prothrombin Time
002.0-002.9
003.0-003.9
038.9
042
060.0-060.9
065.0-065.9
070.0-070.9
075
078.6
078.7
084.8
120.0
121.1
121.3
124
134.2
135
152.0-152.9
155.0-155.2
156.0-156.9
157.0-157.9
188.0-189.9
Typhoid and paratyphoid
Other Salmonella infections
Unspecified Septicemia
Human Immunodeficiency virus (HIV) disease
Yellow fever
Arthropod-borne hemorrhagic fever
Viral hepatitis
Infectious mononucleosis
Hemorrhagic nephrosonephritis
Arenaviral hemorrhagic fever
Blackwater fever
Schistosomiasis
Clonorchiasis
Fascioliasis
Trichinosis
Hirudiniasis
Sarcoidosis
Malignant neoplasm of small intestine, including duodenum
Malignant neoplasm of liver and intrahepatic bile ducts
Malignant neoplasm of gallbladder and extrahepatic bile ducts
Malignant neoplasm of pancreas
Malignant neoplasm of bladder, kidney, and other and unspecified urinary
organs
Secondary malignant neoplasm, liver
Secondary malignant neoplasm, kidney
Secondary malignant neoplasm, other urinary organs
Lymphosarcoma and reticulosarcoma
Other malignant neoplasms of lymphoid and histiocytic tissue
Malignant carcinoid tumors of other and unspecified sites
Secondary neuroendocrine tumor, unspecified site
Secondary neuroendocrine tumor of distant lymph nodes
Secondary neuroendocrine tumor of liver
Secondary neuroendocrine tumor of bone
Secondary neuroendocrine tumor of peritoneum
Secondary Merkel cell carcinoma
Secondary neuroendocrine tumor of other sites
Benign neoplasm of kidney and other urinary organs
Polycythemia vera
Histocytic and mast cells - neoplasm of uncertain behavior
Plasma cells - neoplasm of uncertain behavior
Other lymphatic and hematopoietic tissues
Neoplasm of unspecified nature, bladder
Neoplasm of unspecified nature, other genitourinary organs
Neoplasm of unspecified nature, site unspecified
Hemorrhage and infarction of thyroid
Secondary diabetes mellitus with renal manifestations
Diabetic with renal manifestations
Other and unspecified protein/calorie malnutrition
197.7
198.0
198.1
200.00-200.88
202.00-202.98
209.20-209.29
209.70
209.71
209.72
209.73
209.74
209.75
209.79
223.0-223.9
238.4
238.5
238.6
238.71-238.79
239.4
239.5
239.9
246.3
249.40-249.41
250.40-250.43
263.0-263.9
84
PT (NCD)
PROTHROMBIN TIME
National Coverage Decision November 25, 2002
269.0
269.2
273.0-273.9
275.01
275.02
275.03
275.09
277.1
277.30-277.39
280.0
280.9
281.0
281.1
281.9
285.0
285.1
286.0-286.9
287.0-287.39
287.41
287.49
287.5-287.9
289.81
290.40-290.43
325
342.90-342.92
360.43
362.18
362.30-362.37
362.43
362.81
363.61-363.72
368.9
372.72
374.81
376.32
377.42
377.53
377.62
377.72
379.23
380.31
386.2
386.50
394.0-394.9
395.0
395.2
396.0-396.9
397.0-397.9
398.0-398.99
Deficiency of Vitamin K
Unspecified vitamin deficiency
Disorders of plasma protein metabolism
Hereditary hemochromatosis
Hemochromatosis due to repeated red blood cell transfusions
Other hemochromatosis
Other disorders of iron metabolism
Disorders of porphyrin metabolism
Amyloidosis
Iron deficiency anemia, secondary to blood loss - chronic
Iron deficiency anemia, unspecified
Pernicious anemia
Other Vitamin B12 Deficiency Anemia, NEC
Unspecified Deficiency Anemia, NOS
Sideroblastic anemia
Acute posthemorrhagic anemia
Coagulation defects
Allergic purpura; qualitative platelet defects; other non-thrombocytopenic
purpuras; primary thrombocytopenia
Posttransfusion purpura
Other secondary thrombocytopenia
Thrombocytopenia, unspecified; other specified and unspecified hemorrhagic
conditions
Primary hypercoagulable state
Vascular dementia
Phlebitis and thrombophlebitis of intracranial venous sinuses
Hemiplegia NOS
Hemophthalmos, except current injury
Retinal vasculitis
Retinal vascular occlusion
Hemorrhagic detachment of retinal pigment epithelium
Retinal hemorrhage
Choroidal hemorrhage and rupture, detachment
Unspecified Visual Disturbances
Conjunctival hemorrhage
Hemorrhage of eyelid
Orbital hemorrhage
Hemorrhage in optic nerve sheaths
Disorders of optic chiasm associated with vascular disorders
Disorders of visual pathways associated with vascular disorders
Disorders of visual cortex associated with vascular disorders
Vitreous hemorrhage
Hematoma of auricle or pinna
Vertigo of central origin
Labyrinthine dysfunction, unspecified
Diseases of the mitral valve
Rheumatic aortic stenosis
Rheumatic aortic stenosis with insufficiency
Diseases of mitral and aortic valves
Diseases of other endocardial structures
Other rheumatic heart disease
85
PT (NCD)
PROTHROMBIN TIME
National Coverage Decision November 25, 2002
403.01, 403.11 403.91 Hypertensive chronic kidney disease, with chronic kidney disease stage V or
end stage renal disease
404.02, 404.12 404.92 Hypertensive heart and chronic kidney disease without heart failure and with
chronic kidney disease stage V or end stage renal disease
410.00-410.92
Acute myocardial infarction
411.1
Intermediate coronary syndrome
411.81
Coronary occlusion without myocardial infarction
411.89
Other acute and subacute forms of ischemic heart disease
413.0-413.9
Angina pectoris
414.00-414.07
Coronary atherosclerosis
414.3
Coronary atherosclerosis due to lipid rich plaque
414.4
Coronary atherosclerosis due to calcified coronary lesion
414.8
Other specified forms of chronic ischemic heart disease
414.9
Chronic ischemic heart disease, unspecified
415.0-415.19
Acute pulmonary heart disease
416.9
Chronic pulmonary heart disease, unspecified
423.0
Hemopericardium
424.0
Mitral valve disorders
424.1
Aortic valve disorder
424.90
Endocarditis, valve unspecified, unspecified cause
425.0, 425.11, 425.18 Cardiomyopathy
425.2 - 425.9-425.9
427.0-427.9
Cardiac dysrhythmias
428.0-428.9
Heart failure
429.0-429.4
Ill-defined descriptions and complications of heart disease
429.79
Other certain sequelae of myocardial infarction, not elsewhere classified
430
Subarachnoid hemorrhage
431
Intracerebral hemorrhage
432.0-432.9
Other and unspecified intracranial hemorrhage
433.00-433.91
Occlusion and stenosis of precerebral arteries
434.00-434.91
Occlusion of cerebral arteries
435.0-435.9
Transient cerebral ischemia
436
Acute, but ill-defined cerebrovascular disease
437.0
Cerebral atherosclerosis
437.1
Other generalized ischemic cerebrovascular disease
437.6
Nonpyogenic thrombosis of intracranial venous sinus
440.0-440.9
Atherosclerosis
441.0-441.9
Aortic aneurysm and dissection
443.0-443.9
Other peripheral vascular disease
444.01, 444.09,
Arterial embolism and thrombosis
444.1 - 444.9
447.1
Stricture of artery
447.2
Rupture of artery
447.6
Arteritis, unspecified
448.0
Hereditary hemorrhagic telangiectasia
448.9
Other and unspecified capillary diseases
451.0-451.9
Phlebitis and thrombophlebitis
452
Portal vein thrombosis
453.0-453.9
Other venous embolism and thrombosis
455.2
Internal hemorrhoids with other complication
455.5
External hemorrhoids with other complication
455.8
Unspecified hemorrhoids with other complication
86
PT (NCD)
PROTHROMBIN TIME
National Coverage Decision November 25, 2002
456.0-456.1
456.8
459.0
459.10-459.19
459.2
459.81
459.89
511.81
511.89
514
530.7
530.82
530.86
530.87
531.00-535.71
555.0-555.9
556.0-556.9
557.0-557.9
562.02-562.03
562.10
562.11
562.12
562.13
568.81
569.3
571.0-571.9
572.2
572.4
572.8
573.1-573.9
576.0-576.9
577.0
578.0-578.9
579.0-579.9
581.0-581.9
583.9
584.5-584.9
585.4-585.9
586
593.81-593.89
596.7
596.81
596.82
596.83
596.89
599.70-599.72
607.82
608.83
611.89
620.7
621.4
Esophageal varices
Varices of other sites
Hemorrhage, unspecified
Postphlebitis syndrome
Compression of vein
Venous (peripheral) insufficiency, unspecified
Other, other specified disorders of circulatory system
Malignant pleural effusion
Other specified forms of effusion except tuberculous
Pulmonary congestion and hypostasis
Gastroesophageal laceration - hemorrhage syndrome
Esophageal hemorrhage
Infection of esophagostomy
Mechanical complication of esophagostomy
Gastric ulcer, duodenal ulcer, peptic ulcer, gastrojejunal ulcer, gastritis and
duodenitis
Regional enteritis
Ulcerative colitis
Vascular insufficiency of intestine
Diverticulosis of small intestine with hemorrhage
Diverticulosis of colon w/o hemorrhage
Diverticulitis of colon w/o hemorrhage
Diverticulitis of colon with hemorrhage
Diverticulitis of colon with hemorrhage
Hemoperitoneum (nontraumatic)
Hemorrhage of rectum and anus
Chronic liver disease and cirrhosis
Hepatic Coma
Hepatorenal syndrome
Other sequelae of chronic liver disease
Hepatitis in viral diseases, other and unspecified disorder of liver
Other disorders of Biliary tract
Acute pancreatitis
Gastrointestinal hemorrhage
Intestinal Malabsorption
Nephrotic Syndrome
Nephritis, with unspecified pathological lesion in kidney
Acute Renal Failure
Chronic kidney disease
Renal failure, unspecified
Other specified disorders of kidney and ureter
Hemorrhage into bladder wall
Infection of cystostomy
Mechanical complication of cystostomy
Other complication of cystostomy
Other specified disorders of bladder
Hematuria
Vascular disorders of penis
Vascular disorders of male genital organs
Other specified disorders of breast
Hematoma of broad ligament
Hematometra
87
PT (NCD)
PROTHROMBIN TIME
National Coverage Decision November 25, 2002
622.8
623.6
623.8
624.5
626.2-626.9
627.0
627.1
629.0
632
634.10-634.12
635.10-635.12
636.10-636.12
637.10-637.12
638.1
639.1
639.6
640.00-640.93
641.00-641.93
642.00-642.94
646.70-646.73
649.30-649.34
649.50-649.53
656.00-656.03
658.40-658.43
666.00-666.34
671.20-671.94
673.00-673.84
674.30-674.34
713.2
713.6
719.15
719.16
719.19
729.5
729.81
733.10
746.00-746.9
762.1
767.0,767.11
767.8
770.3
772.0-772.9
774.6
776.0-776.9
780.2
782.3
Other specified noninflammatory disorders of cervix
Vaginal hematoma
Other specified noninflammatory disorders of the vagina
Hematoma of vulva
Abnormal bleeding from female genital tract
Premenopausal menorrhagia
Postmenopausal bleeding
Hematocele female, not classified elsewhere
Missed abortion
Spontaneous abortion, complicated by excessive hemorrhage
Legally induced abortion, complicated by delayed or excessive hemorrhage
Illegally induced abortion, complicated by delayed or excessive hemorrhage
Abortion unspecified, complicated by delayed or excessive hemorrhage
Failed attempted abortion, complicated by delayed or excessive hemorrhage
Delayed or excessive hemorrhage following abortion and ectopic and molar
pregnancies
Complications following abortion and ectopic and molar pregnancies with
embolism
Hemorrhage in early pregnancy
Antepartum hemorrhage, abruptio placentae, and placenta previa
Hypertension complicating pregnancy, childbirth, and the puerperium
Liver disorders in pregnancy
Coagulation defects complicating pregnancy, childbirth, or the puerperium,
unspecified as to episode of care or not applicable
Spotting complicating pregnancy, unspecified as to episode of care or not
applicable
Fetal maternal hemorrhage
Infection of amniotic cavity
Postpartum hemorrhage
Venous complications in pregnancy and the puerperium except legs, vulva
and perineum
Obstetrical pulmonary embolism
Other complications of obstetrical surgical wounds
Arthropathy associated with hematological disorders
Arthropathy associated with hypersensitivity reaction
Hemarthrosis pelvic region and thigh
Lower Leg
Multiple sites
Pain in limb
Swelling of limb
Pathologic fracture, unspecified site
Other Congenital anomalies of heart
Other forms of placental separation and hemorrhage
Birth trauma, subdural and cerebral hemorrhage and injury to scalp
Other specified birth trauma
Pulmonary hemorrhage
Fetal and neonatal hemorrhage
Unspecified fetal and neonatal jaundice
Hemorrhagic disease of the newborn
Syncope and collapse
Edema
88
PT (NCD)
PROTHROMBIN TIME
National Coverage Decision November 25, 2002
782.4
782.7
784.7
784.8
785.4
785.50
786.05
786.30
786.31
786.39
786.50
786.51
786.59
789.00-789.09
789.7
789.1
789.51
789.59
790.92
790.94
791.2
794.8
800.00-800.99
801.00-801.99
802.20-802.9
803.00-803.99
804.00-804.99
805.00-806.9
807.00-807.09
807.10-807.19
808.8-808.9
809.0-809.1
810.00-810.13
811.00-811.19
812.00-812.59
813.10-813.18
813.30-813.33
813.50-813.54
813.90-813.93
819.0-819.1
820.00-821.39
823.00-823.92
827.0-829.1
852.00-853.19
860.0-860.5
861.00-861.32
862.0-862.9
863.0-863.90
863.91-863.95 &
863.99
864.00-864.19
Jaundice, unspecified, not of newborn
Spontaneous ecchymosis
Epistaxis
Hemorrhage from throat
Gangrene
Shock without mention of trauma
Shortness of breath
Hemoptysis, unspecified
Acute idiopathic pulmonary hemorrhage in infants (AIPHI)
Other hemoptysis
Chest pain, unspecified
Precordial pain
Chest pain, other
Abdominal pain
Colic
Hepatomegaly
Malignant Ascites
Other Ascites
Abnormal coagulation profile
Euthyroid sick syndrome
Hemoglobinuria
Abnormal Liver Function Study
Fracture of vault of skull
Fracture of base of skull
Fracture of face bones
Other and unqualified skull fractures
Multiple fractures involving skull or face with other bones
Fracture, vertebral column
Fractures of rib(s), closed
Fracture of rib(s), open
Unspecified fracture of pelvis
Ill-defined fractures of bones of trunk
Fracture of clavicle
Fracture of scapula
Fracture of humerus
Fracture of radius and ulna, upper end, open
Shaft, open
Lower end, open
Fracture unspecified part, open
Multiple fractures involving upper both upper limbs, closed and open
Fracture of neck of femur
Fracture of tibia and fibula
Other multiple lower limb
Subarachnoid subdural, and extradural hemorrhage, following injury, Other
and specified intracranial hemorrhage following injury
Traumatic pneumothorax and hemothorax
Injury to heart and lung
Injury to other and unspecified intrathoracic organs
Injury to gastrointestinal tract
Injury to Pancreas
Injury to liver
89
PT (NCD)
PROTHROMBIN TIME
National Coverage Decision November 25, 2002
865.00-865.19
866.00-866.13
867.0-867.9
868.00-868.19
869.0-869.1
900.00-900.9
901.0-901.9
902.0-902.9
903.00-903.9
904.0-904.9
920-924.9
925.1-929.9
958.2
959.9
964.0-964.9
980.0-980.9
981
982.0-982.8
987.0-987.9
989.0-989.9
995.20
Injury to spleen
Injury to kidney
Injury to pelvic organs
Injury to other intra-abdominal organs
Internal injury to unspecified or ill defined organs
Injury to blood vessels of head and neck
Injury to blood vessels of the thorax
Injury to blood vessels of the abdomen and pelvis
Injury to blood vessels of upper extremity
Injury to blood vessels of lower extremity and unspecified sites
Contusion with intact skin surface
Crushing injury
Secondary and recurrent hemorrhage
Injury, unspecified site
Poisoning by agents primarily affecting blood constituents
Toxic effect of alcohol
Toxic effect of petroleum products
Toxic effects of solvents other than petroleum-based
Toxic effect of other gases, fumes or vapors
Toxic effect of other substances chiefly non-medicinal as to source
Unspecified adverse effect of unspecified drug, medicinal and biological
substance
995.21
Arthus phenomenon
995.24
Failed moderate sedation during procedure
995.27
Other drug allergy
995.29
Unspecified adverse effect of other drug, medicinal and biological substance
996.82
Complication of transplanted liver
997.02
Iatrogenic cerebrovascular infarction or hemorrhage
997.41
Retained cholelithiasis following cholecystectomy
997.49
Other digestive system complications
998.11-998.12
Hemorrhage or hematoma complicating a procedure
999.2
Other vascular complications
999.80
Transfusion reaction, unspecified
999.83
Hemolytic transfusion reaction, incompatibility unspecified
999.84
Acute hemolytic transfusion reaction, incompatibility unspecified
999.85
Delayed hemolytic transfusion reaction, incompatibility unspecified
999.89
Other transfusion reaction
V08
Asymptomatic HIV infection
V12.1
History of nutritional deficiency
V12.3
Personal history of diseases of blood and blood-forming organs
V12.50-V12.55, V12.59 Personal history of transient ischemic attack, cerebral infarction, or
pulmonary embolism without residual deficits
V15.1
Personal history of surgery to heart and great vessels
V15.21
Personal history of undergoing in utero procedure during pregnancy
V15.22
Personal history of undergoing in utero procedure while a fetus
V15.29
Personal history of surgery of other major organs
V42.0
Kidney replaced by transplant
V42.1
Heart replaced by transplant
V42.2
Heart valve replaced by transplant
V42.6
Lung replaced by transplant
V42.7
Liver replaced by transplant
V42.81-V42.89
Other specified organ or tissue replaced by transplant
90
PT (NCD)
PROTHROMBIN TIME
National Coverage Decision November 25, 2002
V43.21, V43.22
V43.3
V43.4
V58.2
V58.61
V58.83
Heart replaced by other means
Heart valve replaced by other means
Blood vessel replaced by other means
Transfusion of blood products
Long term (current) use of anticoagulants
Encounter for therapeutic drug monitoring
Reviewed:
April 2013
91
PT (NCD)
PARTIAL THROMBOPLASTIN TIME
National Coverage Decision November 25, 2002
CPT: 85730
Partial Thromboplastin Time (PTT)
002.0-002.9
003.0-003.9
038.9
042
060.0-060.9
065.0-065.9
070.0-070.9
075
078.6
078.7
120.0
121.1
121.3
124
135
155.0-155.2
197.7
238.4
238.71-238.79
239.9
246.3
249.40-249.41
250.40-250.43
269.0
273.0-273.9
275.01
275.02
275.03
275.09
275.1
275.2
275.3
275.40-275.49
275.5
275.8-275.9
Typhoid and paratyphoid
Other Salmonella infections
Unspecified Septicemia
Human immunodeficiency virus (HIV) disease
Yellow fever
Arthropod borne hemorrhagic fever
Viral Hepatitis
Infectious mononucleosis
Hemorrhagic nephrosonephritis
Arenaviral hemorrhagic fever
Schistosomiasis haematobium
Clonorchiasis
Fascioliasis
Trichinosis
Sarcoidosis
Malignant neoplasm of liver and intrahepatic bile ducts
Malignant neoplasm of liver, specified as secondary
Polycythemia vera
Other lymphatic and hemapoietic tissues
Neoplasm of unspecified nature, site unspecified
Hemorrhage and infarction of thyroid
Secondary diabetes mellitus with renal manifestations
Diabetic with renal manifestations
Deficiency of Vitamin K
Disorders of plasma protein metabolism
Hereditary hemochromatosis
Hemochromatosis due to repeated red blood cell transfusions
Other hemochromatosis
Other disorders of iron metabolism
Disorders of copper metabolism
Disorders of magnesium metabolism
Disorders of phosphorus metabolism
Disorders of calcium metabolism
Hungry bone syndrome
Other specified disorders of mineral metabolism, and unspecified disorder of
mineral metabolism
Disorders of porphyrin metabolism
Amyloisodosis
Acute posthemorrhagic anemia
Congenital factor VIII disorder - Hemophilia A
Congenital factor IX disorder - Hemophilia B
Other congenital factor deficiencies
von Willebrand's disease
Acquired hemophilia
Antiphospholipid antibody with hemorrhagic disorder
Other hemorrhagic disorder due to intrinsic circulating anticoagulants,
antibodies, or inhibitors
Defibrination syndrome
277.1
277.30-277.39
285.1
286.0
286.1
286.2-286.3
286.4
286.52
286.53
286.59
286.6
92
PTT (NCD)
PARTIAL THROMBOPLASTIN TIME
National Coverage Decision November 25, 2002
286.7
286.9
287.0-287.39
287.41
287.49
287.5-287.9
289.0
289.81
325
360.43
362.30-362.37
362.43
362.81
363.61-363.63
363.72
368.9
372.72
374.81
376.32
377.42
379.23
380.31
403.01, 403.11,
03.91
404.02, 404.12,
404.92
410.00-410.92
423.0
427.31
427.9
428.0
429.79
430-432.9
433.00-433.91
434.00-434.91
435.9
444.01, 444.09,
444.1 - 444.9
446.6
447.2
448.0
451.0-451.9
453.0-453.9
456.0
456.1
456.8
459.89
530.7
530.82
Acquired coagulation factor deficiency
Other and unspecified coagulation defects
Allergic purpura; qualitative platelet defects; other non-thrombocytopenic
purpuras; primary thrombocytopenia
Posttransfusion purpura
Other secondary thrombocytopenia
Thrombocytopenia, unspecified; other specified and unspecified hemorrhagic
conditions
Polycythemia, secondary
Primary hypercoagulable state
Phlebitis and thrombophlebitis of intracranial venous sinuses
Hemophthalmos, except current injury
Retinal vascular occlusion
Hemorrhagic detachment of retinal pigment epithelium
Retinal hemorrhage
Choroidal hemorrhage
Choroidal detachment
Unspecified Visual Disturbances
Conjunctive hemorrhage
Hemorrhage of eyelid
Orbital hemorrhage
Hemorrhage in optic nerve sheaths
Vitreous hemorrhage
Hematoma of auricle or pinna
Hypertensive chronic kidney disease, with chronic kidney disease stage V or
end stage renal disease
Hypertensive heart and chronic kidney disease without heart failure and with
chronic kidney disease stage V or end stage renal disease
Acute myocardial infarction
Hemopericardium
Atrial fibrillation
Cardiac dysrhythmias, unspecified
Congestive heart failure, unspecified
Mural thrombus
Cerebral hemorrhage
Occlusion and stenosis of precerebral arteries
Occlusion of cerebral arteries
Focal neurologic deficit
Arterial embolism and thrombosis
Thrombotic microangiopathy
Rupture of artery
Hereditary Hemorrhagic telangiectasia
Phlebitis and thrombophlebitis
Other Venous emboli and thrombosis
Esophageal varices with bleeding
Esophageal varices without bleeding
Varices of other sites
Ecchymosis
Gastroesophageal laceration - hemorrhage syndrome
Esophageal hemorrhage
93
PTT (NCD)
PARTIAL THROMBOPLASTIN TIME
National Coverage Decision November 25, 2002
531.00-535.71
537.83
537.84
556.0-557.9
562.02-562.03
562.12
562.13
568.81
569.3
570
571.0-573.9
576.0-576.9
577.0
578.0-578.9
579.0-579.9
581.0-581.9
583.9
584.5-584.9
585.4
585.5
585.6
585.9
586
593.81-593.89
596.7
596.81
596.82
596.83
596.89
599.70-599.72
607.82
608.83
611.89
Gastric ulcer, duodenal ulcer, peptic ulcer, gastrojejunal ulcer, gastritis and
duodenitis
Angiodysplasia of stomach and duodenum with hemorrhage
Dielulafoy lesion (Hemorrhagic) of stomach and duodenum
Hemorrhagic bowel disease
Diverticulosis of small intestine with hemorrhage
Diverticulosis of colon with hemorrhage
Diverticulitis of colon with hemorrhage
Hemoperitoneum (nontraumatic)
Hemorrhage of rectum and anus
Acute and subacute necrosis of liver
Liver disease (in place of specific codes listed)
Biliary tract disorders
Acute pancreatitis
Gastrointestinal Hemorrhage
Malabsorption
Nephrotic Syndrome
Nephritis, with unspecified pathological lesion in kidney
Acute Renal Failure
Chronic kidney disease, Stage IV (severe)
Chronic kidney disease, Stage V
End stage renal disease
Chronic kidney disease, unspecified
Renal failure
Other disorders of kidney and ureter, with hemorrhage
Hemorrhage into bladder wall
Infection of cystostomy
Mechanical complication of cystostomy
Other complication of cystostomy
Other specified disorders of bladder
Hematuria
Penile hemorrhage
Vascular disorders of male genital organs
Other specified disorders of Breast
620.7
621.4
622.8
623.6
623.8
624.5
626.6
626.7
627.0
627.1
629.0
632
634.00-634.92
635.10-635.12
636.10-636.12
637.10-637.12
638.1
Hemorrhage of broad ligament
Hematometra
Other specified disorders of cervix, with hemorrhage
Vaginal hematoma
Other specified diseases of the vagina, with hemorrhage
Hematoma of vulva
Metrorrhagia
Postcoital bleeding
Premenopausal bleeding
Postmenopausal bleeding
Hematocele female not elsewhere classified
Missed abortion
Spontaneous abortion
Legally induced abortion, complicated by delayed or excessive hemorrhage
Illegally induced abortion, complicated by delayed or excessive hemorrhage
Abortion unspecified, complicated by delayed or excessive hemorrhage
Failed attempt abortion, complicated by delayed or excessive hemorrhage
94
PTT (NCD)
PARTIAL THROMBOPLASTIN TIME
National Coverage Decision November 25, 2002
639.1
639.6
640.00-640.93
641.00-641.93
642.00-642.94
646.70-646.73
649.30-649.34
649.50-649.53
656.00-656.03
658.40-658.43
666.00-666.34
671.20-671.54
673.00-673.84
674.30-674.34
710.0
713.2
713.6
719.10-719.19
729.5
729.81
733.10-733.19
762.1
764.90-764.99
767.0,767.11
767.8
770.3
772.0-772.9
774.0-774.7
776.0-776.9
780.2
782.4
782.7
784.7
784.8
785.4
785.50
786.05
786.30
786.31
786.39
786.50
786.59
789.00-789.09
789.7
790.92
Delayed or excessive hemorrhage following abortion and ectopic and molar
pregnancies
Complications following abortion and ectopic and molar pregnancies,
embolism
Hemorrhage in early pregnancy
Antepartum hemorrhage
Hypertension complicating pregnancy, childbirth, and the puerperium
Liver disorders in pregnancy
Coagulation defects complicating pregnancy, childbirth, or the puerperium,
unspecified as to episode of care or not applicable
Spotting complicating pregnancy, unspecified as to episode of care or not
applicable
Fetal maternal hemorrhage
Infection of amniotic cavity
Postpartum hemorrhage
Phlebitis in pregnancy
Obstetrical pulmonary embolus
Other complications of surgical wounds, with hemorrhage
Systemic Lupus erythematosus
Arthropathy associated with hematologic disorders (note: may not be used
without indicating associated condition first)
Arthropathy associated with Henoch Schonlein (note: may not be used
without indicating associated condition first)
Hemarthrosis
Leg pain/calf pain
Swelling of limb
Pathologic fracture associated with fat embolism
Other forms of placental separation with hemorrhage (affecting newborn codedo not assign to mother's record)
Fetal intrauterine growth retardation
Subdural and cerebral hemorrhage
Other specified birth trauma, with hemorrhage
Fetal and newborn pulmonary hemorrhage
Fetal and neonatal hemorrhage
Other perinatal jaundice
Hemorrhagic disease of the newborn
Syncope
Jaundice, unspecified, not of newborn
Spontaneous ecchymoses Petechiae
Epistaxis
Hemorrhage from throat
Gangrene
Shock
Shortness of breath
Hemoptysis, unspecified
Acute idiopathic pulmonary hemorrhage in infants (AIPHI)
Other hemoptysis
Chest pain, unspecified
Chest pain
Abdominal pain
Colic
Abnormal coagulation profile
95
PTT (NCD)
PARTIAL THROMBOPLASTIN TIME
National Coverage Decision November 25, 2002
800.00-800.99
801.00-801.99
802.20-802.9
803.00-803.99
804.00-804.99
805.00-806.9
807.00-807.09
807.10-807.19
808.8-808.9
809.0-809.1
810.00-810.13
811.00-811.19
812.00-812.59
813.10-813.18
813.30-813.33
813.50-813.54
813.90-813.93
819.0-819.1
820.00-821.39
823.00-823.92
827.0-829.1
852.00-853.19
860.0-860.5
861.00-861.32
862.0-862.9
863.0-863.99
864.00-864.19
865.00-865.19
866.00-866.13
867.0-867.9
868.00-868.19
869.0-869.1
900.00-900.9
901.0-901.9
902.0-902.9
903.00-903.9
904.0-904.9
920-924.9
925.1-929.9
958.2
959.9
964.2
964.5
964.7
980.0
989.5
995.20
995.21
995.24
995.27
Fracture of vault of skull
Fracture of base of skull
Fracture of face bones
Other fracture, skull
Multiple fractures, skull
Fracture, vertebral column
Fractures of rib(s), closed
Fractures of rib(s), open
Fracture of pelvis
Fracture of trunk
Fracture of clavicle
Fracture of scapula
Fracture of humerus
Fracture of radius and ulna, upper end, open
Fracture of radius and ulna, shaft, open
Fracture of radius and ulna, lower end, open
Fracture of radius and ulna, unspecified part, open
Multiple fractures
Femur
Tibia and fibula
Other multiple lower limb
Subarachnoid subdural, and extradural hemorrhage, following injury, Other
and specified intracranial hemorrhage following injury
Traumatic pneumothorax and hemothorax
Injury to heart and lung
Injury to other and unspecified intrathoracic organs
Injury to gastrointestinal tract
Injury to liver
Injury to spleen
Injury to kidney
Injury to pelvic organs
Injury to other intra-abdominal organs
Internal injury to unspecified or ill defined organs
Injury to blood vessels of head and neck
Injury to blood vessels of the thorax
Injury to blood vessels of the abdomen and pelvis
Injury to blood vessels of upper extremity
Injury to blood vessels of lower extremity and unspecified sites
Contusion with intact skin surface
Crushing injury
Secondary and recurrent hemorrhage
Injury, unspecified site
Poisoning by anticoagulants
Poisoning by anticoagulant antagonists
Poisoning by natural blood and blood products
Toxic effects of alcohol
Snake venom
Unspecified adverse effect of unspecified drug, medicinal and biological
substance
Arthus phenomenon
Failed moderate sedation during procedure
Other drug allergy
96
PTT (NCD)
PARTIAL THROMBOPLASTIN TIME
National Coverage Decision November 25, 2002
995.29
996.70-996.79
997.02
998.11
998.12
999.2
V12.3
V58.2
V58.61
V58.83
Unspecified adverse effect of other drug, medicinal and biological substance
Other complications of internal prosthetic device
Iatrogenic cerebrovascular infarction or hemorrhage
Hemorrhage or hematoma complicating a procedure
Hematoma complicating a procedure
Other vascular complications of medical care
Personal history of diseases of blood and blood forming organs
Admission for Transfusion of blood products
Long term (current use) of anticoagulants
Encounter for therapeutic drug monitoring
Reviewed:
April 2013
97
PTT (NCD)
QUALITATIVE DRUG SCREENING
Medicare A Medical Policy August 13, 2012
CPT: 80102
CPT: G0431
CPT: G0434
Drug confirmation
Drug screen multiple class
Drug screen multi drug class
276.2
304.01
304.90
305.90
345.10
345.11
345.3
345.90-345.91
Acidosis
Opioid type dependence continuous use
Unspecified drug dependence unspecified use
Other or mixed or unspecified drug abuse 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 - other second degree atrioventricular
block
Long QT syndrome
Paroxysmal supraventricular tachycardia
Paroxysmal ventricular tachycardia
Coma
Alteration of consciousness other
Hallucinations
Other convulsions
Poisoning by antiallergic and antiemetic drugs
Poisoning by opium (alkaloids) unspecified - poisoning by methadone
Poisoning by other opiates and related narcotics
Poisoning by salicylates
Poisoning by aromatic analgesics not elsewhere classified - poisoning by
pyrazole derivatives
Poisoning by propionic acid derivatives
Poisoning by hydantoin derivatives
Poisoning by barbiturates - poisoning by mixed sedatives not elsewhere
classified
Poisoning by other sedatives and hypnotics - poisoning by unspecified
sedative or hypnotic
Poisoning by antidepressant, unspecified - poisoning by tricyclic
antidepressants
Poisoning by other antidepressants
Poisoning by phenothiazine-based tranquilizers - poisoning by
psychodysleptics (hallucinogens)
Poisoning by psychostimulant, unspecified - poisoning by methylphenidate
Poisoning by other psychostimulants
Poisoning by other specified 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
426.10-426.13
426.82
427.0
427.1
780.01
780.09
780.1
780.39
963.0
965.00-965.02
965.09
965.1
965.4-965.5
965.61
966.1
967.0-967.6
967.8-967.9
969.00-969.05
969.09
969.1-969.6
969.70-969.70
969.79
969.8-969.9
970.81
970.89
972.1
977.9
98
QDS (LCD)
QUALITATIVE DRUG SCREENING
Medicare A Medical Policy August 13, 2012
V58.69
V71.09
Long-term (current) use of other medications
Observation of other suspected mental condition
Reviewed:
April 2013
99
QDS (LCD)
THYROID TESTING
National Coverage Decision November 25, 2002
CPT: 84436
CPT: 84439
CPT: 84443
CPT: 84479
Thyroxine; total
Thyroxine; free
Thyroid stimulating hormone (TSH)
Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)
017.50-017.56
183.0
193
194.8
198.89
220
226
227.3
234.8
237.4
239.7
240.0-240.9
241.0-241.9
242.00-242.91
243
244.0-244.9
245.0-245.9
246.0-246.9
249.40-249.41
250.00-250.93
252.1
253.1
253.2
253.3
253.4
253.7
255.2
255.41
255.42
256.31-256.39
257.2
258.0-258.9
262
263.0-263.9
266.0
272.0
272.2
272.4
275.40-275.49
275.5
276.0
276.1
278.3
279.41-279.49
Tuberculosis of the thyroid gland
Malignant neoplasm of ovary
Malignant neoplasm of thyroid gland
Malignant neoplasm of other endocrine glands and related structures, other
Secondary malignant neoplasm of the thyroid
Benign neoplasm of ovary
Benign neoplasm of thyroid gland
Benign neoplasm of pituitary gland and craniopharyngeal duct
Carcinoma in situ of other and unspecified sites
Neoplasm of uncertain behavior of other and unspecified endocrine glands
Neoplasm of unspecified nature, thyroid gland
Goiter specified and unspecified
Nontoxic nodular goiter
Thyrotoxicosis with or without goiter
Congenital hypothyroidism
Acquired hypothyroidism
Thyroiditis
Other disorders of thyroid
Secondary diabetes mellitus with renal manifestations
Diabetes mellitus
Hypoparathyroidism
Other and unspecified anterior pituitary hyper function
Panhypopituitarism
Pituitary dwarfism
Other anterior pituitary disorders
Iatrogenic pituitary disorders
Adrenogenital disorders
Glucocorticoid deficiency
Mineralocorticoid deficiency
Ovarian failure
Testicular hypofunction
Polyglandular dysfunction
Malnutrition, severe
Malnutrition, other and unspecified
Ariboflavinosis
Pure hypercholesterolemia
Mixed hyperlipidemia
Other and unspecified hyperlipidemia
Calcium disorders
Hungry bone syndrome
Hyposmolality and/or hypernatremia
Hyposmolality and/or hyponatremia
Hypercarotenemia
Autoimmune disorder, not classified elsewhere
100
THYROID (NCD)
THYROID TESTING
National Coverage Decision November 25, 2002
281.0
281.9
283.0
285.9
290.0
290.10-290.13
290.20-290.21
290.3
293.0-293.1
293.81-293.89
294.8
296.00-296.99
297.0
297.1
297.9
298.3
300.00-300.09
307.9
310.1
311
327.00-327.8
331.0, 331.11,
331.19, 331.2
331.83
333.1
333.99
354.0
356.9
358.1
359.5
359.9
368.2
372.71
372.73
374.41
374.82
376.21
376.22
376.30-376.31
376.33-376.34
378.50-378.55
401.0-401.9
403.00-403.91
404.00-404.93
423.9
425.7
427.0
427.2
427.31
427.89
427.9
Pernicious anemia
Unspecified deficiency anemia
Autoimmune hemolytic anemia
Anemia, unspecified
Senile dementia, uncomplicated
Presenile dementia
Senile dementia with delusional or depressive features
Senile dementia with delirium
Delirium
Transient organic mental disorders
Other specified organic brain syndromes
Affective psychoses
Paranoid state, simple
Paranoia
Unspecified paranoid state
Acute paranoid reaction
Anxiety states
Agitation-other and unspecified special symptoms or syndromes, not
elsewhere classified
Organic personality syndrome
Depressive disorder, not elsewhere classified
Other organic sleep disorders
Alzheimer's, pick's disease, Senile degeneration of brain
Mild cognitive impairment, so stated
Essential and other specified forms of tremor
Other extrapyramidal diseases and abnormal movement disorders
Carpal Tunnel syndrome
Idiopathic peripheral neuropathy, unspecified polyneuropathy
Myasthenic syndromes in diseases classified elsewhere
Myopathy in endocrine diseases classified elsewhere
Myopathy, unspecified
Diplopia
Conjunctival hyperemia
Conjunctival edema
Lid retraction or lag
Eyelid edema
Thyrotoxic exophthalmos
Exophthalmic ophthalmoplegia
Exophthalmic conditions, unspecified and constant
Orbital edema or congestion, intermittent exophthalmos
Paralytic strabismus
Essential hypertension
Hypertensive renal disease
Hypertensive heart and renal disease
Unspecified disease of pericardium
Nutritional and metabolic cardiomyopathy
Paroxysmal supraventricular tachycardia
Paroxysmal tachycardia, unspecified
Atrial fibrillation
Other specified cardiac dysrhythmia
Cardiac dysrhythmia, unspecified
101
THYROID (NCD)
THYROID TESTING
National Coverage Decision November 25, 2002
428.0
428.1
429.3
511.9
518.81
529.8
560.1
564.00-564.09
564.7
568.82
625.3
626.0-626.2
626.4
648.10-648.14
676.20-676.24
698.9
701.1
703.8
704.00-704.09
709.01
710.0-710.9
728.2
728.87
728.9
729.1
729.82
730.30-730.39
733.02
733.09
750.15
759.2
780.01
780.02
780.09
780.50-780.52
780.60-780.66
780.71-780.79
780.8
780.93
780.94
780.96
780.97
780.99
781.0
781.3
782.0
782.3
782.8
782.9
783.0
783.1
Congestive heart failure
Left heart failure
Cardiomegaly
Unspecified pleural effusion
Acute respiratory failure
Other specified conditions of the tongue
Paralytic ileus
Constipation
Megacolon, other than Hirschsprung's
Peritoneal effusion (chronic)
Dysmenorrhea
Disorders of menstruation
Irregular menstrual cycle
Other current conditions in the mother, classifiable elsewhere, but
complicating pregnancy, childbirth, or the puerperium, thyroid dysfunction
Engorgement of breast associated with childbirth and disorders of lactation
Unspecified pruritic disorder
Keratoderma, acquired (dry skin)
Other specified diseases of nail (Brittle nails)
Alopecia
Vitiligo
Diffuse disease of connective tissue
Muscle wasting
Muscle weakness
Unspecified disorder of muscle, ligament, and fascia
Myalgia and myositis, unspecified
Musculoskeletal cramp
Periostitis without osteomyelitis
Idiopathic osteoporosis
Osteoporosis, drug induced
Macroglossia, congenital
Anomaly of other endocrine glands
Coma
Transient alteration of awareness
Alteration of consciousness, other
Insomnia
Fever and other physiologic disturbances of temperature regulation
Malaise and fatigue
Hyperhidrosis
Memory Loss
Early satiety
Generalized pain
Altered mental status
Other general symptoms (hyperthermia)
Abnormal involuntary movements
Lack of coordination, ataxia
Disturbance of skin sensation
Localized edema
Changes in skin texture
Other symptoms involving skin and integumentary tissues
Anorexia
Abnormal weight gain
102
THYROID (NCD)
THYROID TESTING
National Coverage Decision November 25, 2002
783.21
783.6
784.1
784.42
784.43
784.44
784.49
784.51
784.59
785.0
785.1
785.9
786.09
786.1
787.20-787.29
787.91-787.99
789.51
789.59
793.99
794.5
796.1
799.21
799.22
799.23
799.24
799.25
799.29
990
V10.87
V10.88
V10.91
V12.21
V12.29
V58.69
V67.00-V67.9
Abnormal loss of weight
Polyphagia
Throat pain
Dysphonia
Hypernasality
Hyponasality
Voice disturbance
Dysarthria
Other speech disturbance
Tachycardia, unspecified
Palpitations
Other symptoms involving cardiovascular system
Other symptoms involving respiratory system
Stridor
Dysphagia
Other symptoms involving digestive system
Malignant Ascites
Other Ascites
Other nonspecific abnormal findings on radiological and other examinations
of body structure
Thyroid, abnormal scan or uptake
Other nonspecific abnormal findings, abnormal reflex
Nervousness
Irritability
Impulsiveness
Emotional lability
Demoralization and apathy
Other signs and symptoms involving emotional state
Effects of radiation, unspecified
Personal history of malignant neoplasm of the thyroid
Personal history of malignant neoplasm of other endocrine gland
Personal history of malignant neuroendocrine tumor
Personal history of gestational diabetes
Personal history of other endocrine, metabolic, and immunity disorders
Long tern (current) use of other medications
Follow-up examination
Reviewed:
April 2013
103
THYROID (NCD)
URINE CULTURE
National Coverage Decision November 25, 2002
CPT: 87086
CPT: 87088
CPT: 87184
CPT: 87186
003.1
038.0-038.9
276.2
276.4
286.6
288.00-288.09
288.8
306.53
306.59
518.82
570
580.0-580.9
583.0-583.9
585.6
590.00-590.9
592.0-592.9
593.0-593.9
594.0-594.9
595.0-595.9
597.0
597.80-597.89
598.00-598.01
599.0
599.70
599.71
599.72
600.00-600.91
601.0-601.9
602.0-602.9
604.0-604.99
608.0-608.9
614.0-614.9
615.0-615.9
616.0
616.10-616.11
616.2-616.9
619.0-619.9
625.6
Culture, bacterial, quantitative, colony count, urine
Culture, bacterial; with isolation and presumptive identification of each
isolates, urine
Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer
agents)
Susceptibility studies, antimicrobial agent; microdilution or agar dilution
(minimum inhibitory concentration (MIC) or breakpoint), each multiantimicrobial, per plate
Salmonella septicemia
Septicemia
Acidosis
Metabolic acidosis/alkalosis
Defibrination syndrome/disseminated intravascular coagulation
Agranulocytosis/neutropenia
Other specified disease of white blood cells including leukemoid
reaction/leukocytosis
Psychogenic dysuria
Other psychogenic genitourinary malfunction
Other pulmonary insufficiency, not elsewhere classified
Acute and subacute necrosis of liver
Acute glomerulonephritis
Nephritis and Nephropathy, not specified as acute or chronic
End stage renal disease
Infections of kidney/pyelonephritis acute and chronic
Calculus of kidney and ureter
Other disorders of kidney and ureter (cyst, stricture, obstruction, reflux, etc.)
Calculus of lower urinary tract
Cystitis
Urethritis, not sexually transmitted and urethral syndrome
Other urethritis
Urethral stricture due to infection
Urinary tract infection, site not specified
Hematuria
Gross hematuria
Microscopic hematuria
Hyperplasia of prostate
Inflammatory diseases of prostate
Other disorders of prostate (calculus, congestion, atrophy, etc.)
Orchitis and epididymitis
Other disorders of male genital organs (seminal vesiculitis, spermatocele,
etc.)
Inflammatory disease of ovary, fallopian tube, pelvic cellular tissue, and
peritoneum
Inflammatory disease of uterus, except cervix
Cervicitis and endocervicitis
Vaginitis and vulvovaginitis
Other inflammatory conditions of cervix, vagina and vulva
Fistual involving female genital tract
Stress incontinence, female
104
URINE CULTURE (NCD)
URINE CULTURE
National Coverage Decision November 25, 2002
639.0
799.3
939.0
939.3
V44.50-V44.6
V55.5-V55.6
V58.69
Genital tract and pelvic infection complicating abortion, ectopic or molar
pregnancies
Shock complicating abortion, ectopic or molar pregnancies
Infections of genitourinary tract in pregnancy
Major puerperal infection
Puerperal endometritis
Puerperal sepsis
Puerperal septic thrombophlebitis
Other major puerperal infection
Pyrexia of unknown origin during the puerperium
Backache, unspecified
Septicemia (Sepsis) of newborn
General symptoms, transient alteration of awareness
Fever and other physiologic disturbances of temperature regulation
Febrile nonhemolytic transfusion reaction
Other malaise and fatigue
Memory loss
Early satiety
Generalized pain
Altered mental status
Other general symptoms
Tachycardia, unspecified
Shock without mention of trauma
Symptoms involving urinary system (renal colic, dysuria, retention of urine,
incontinence of urine, frequency, polyuria, nocturia, oliguria, anuria, other
abnormality of urination, urethral discharge, extravasation of urine, other
symptoms of urinary system)
Abdominal pain
Abdominal tenderness
Colic
Bacteremia
Nonspecific findings on examination of urine (proteinuria, chyluria,
hemoglobinuria, myoglobinuria, biliuria, glycosuria, acetonuria, other cells
and casts in urine, other nonspecific findings on examination of urine)
Debility, unspecified (only for declining functional status)
Foreign body in genitourinary tract, bladder and urethra
Foreign body in genitourinary tract, penis
Artificial cystostomy or other artificial opening of urinary tract status
Attention to cystostomy or other artificial opening of urinary tract
Long-term (current) use of other medications
Reviewed:
April 2013
639.5
646.60-646.64
670.00-670.04
670.10-670.14
670.20-670.24
670.30-670.34
670.80-670.84
672.00-672.04
724.5
771.81-771.83
780.02
780.60-780.65
780.66
780.79
780.93
780.94
780.96
780.97
780.99
785.0
785.50-785.59
788.0-788.99
789.00-789.09
789.60-789.69
789.7
790.7
791.0-791.9
105
URINE CULTURE (NCD)
Common ICD-9 Codes
This list comprises only the most commonly used ICD-9 codes and is not intended to be all-inclusive. It is provided as
an "at-a glance" tool to supplement the LCD & NCD Policies. ICD-9 codes must always be substantiated by patients'
medical records.
AFP - Alpha Fetoprotein
571.5
Cirrhosis of the liver, unspecified
070.32
Hepatitis B, Chronic
070.54
Hepatitis C, Chronic
795.89
Other abnormal tumor markers
571.49
Other chronic hepatitis
BNP - B-type Natriuretic Peptide
519.11
Acute bronchospasm
493.92
Asthma unspecified with (acute)
493.22
Chronic obstructive asthma with (acute)
428.0
Congestive heart failure, unspec
428.9
Heart failure unspecified
428.1
Left heart failure
425.4
Orther primary cardiomyopathies
786.09
Respiratory abnormality other
786.05
Shortness of breath
786.07
Wheezing
CA125
V10.43 Hx malignant neoplasm, ovary
183.0
Malignant neoplasm of the ovary
795.89
Other abnormal tumor markers
789.39
Pelvic swelling, mass or lump
CA15-3/CA27.29
174.9
CA of female breast, unspecified
V10.3
Hx of malignant neoplasm, breast
795.89
Other abnormal tumor markers
198.81
Secondary malignant neoplasm, breast
CA19-9
V10.09 Hx of malig neoplasm to other GI sites
156.0
Malignant neoplasm , gallbladder
795.89
Other abnormal tumor markers
157.9
Pancreatic CA, part unspecified
COMPLETE BLOOD COUNT
789.00
Abdominal pain, site unspecified
783.21
Abnormal loss of weight
280.9
Anemia, Iron Deficiency
285.9
Anemia, unspecified
281.9
Anemia, unspecified deficiency
136.9
Infection, unspecified
V58.61 Long term (current) use of anticoags
V58.69 Long term (current) use of other meds
041.12
MRSA
CARCINOEMBRYONIC ANTIGEN (CEA)
V67.2
Follow-up post chemotherapy
V10.05 Hx of malignant neoplasm of colon
153.9
Malignant neoplasm of colon
183.0
Malignant neoplasm of ovary
150.9
Malignant neoplasm of the esophagus
790.99
Nonspecific findings on exam of blood
795.89
Other abnormal tumor markers
106
DIGOXIN
427.31 Atrial fibrillation
429.2
Cardiovascular disease, unspecified
428.0
Congestive Heart Failure (CHF)
244.9
Hypothyroidism, unspecified
V58.69 Long term (current) use of other meds
780.79 Malaise and fatigue
586
Renal Failure, unspecified
276.7
Hyperkalemia (Hyperpotassemia)
784.0
Headache
780.2
Syncope & collapse
GGT - Gamma Glutamyltransferase
571.5
Cirrhosis of the liver, unspecified
250.00 Diabetes mellitus
562.11 Diverticulitis of colon
070.30 Hepatitis B, unspecified
789.1
Hepatomegaly
042
HIV disease
272.4
Hyperlipidemia
782.4
Jaundice, unspecified, not of newborn
V58.61 Long term (current) use of anticoags
V58.69 Long term (current) use of other meds
780.79 Malaise and fatigue
790.5
Nonspecific abn'l serum enzyme levels
790.4
Nonspecific elevation of transaminase or
586
Renal Failure, unspecified
079.99 Unspecified viral infection
GLUCOSE
783.21 Abnormal loss of weight
783.1
Abnormal weight gain
786.50 Chest pain, unspecified
414.00 Coronary Artery Disease (CAD)
250.00 Diabetes mellitus
780.4
Dizziness and giddiness
790.29 Hyperglycemia
272.4
Hyperlipidemia
251.2
Hypoglycemia
V58.69 Long term (current) use of other meds
780.79 Malaise and fatigue
263.9
Malnutrition, unspecified
729.1
Myalgia & Fibromyalgia
791.0
Proteinuria
780.39 Seizures, not otherwise specified
GLYCOLATED HEMOGLOBIN (HGB A1C)
250.00 Diabetes Mellitis
790.29 Hyperglycemia
251.2
Hypoglycemia unspecified
V58.69 Long term (current) use of other meds
275.09 Other disorders of iron metabolism
577.1
Pancreatitis, chronic
579.3
Unspecified surgical nonabsorption
April 2013
Common ICD-9 Codes
HCG-QUANT
V10.43 Hx malignant neoplasm, ovary
V10.47 Hx malignant neoplasm, testis
186.9
Malig neoplasm of other, unspec testis
183.0
Malignant neoplasm of the ovary
632
Missed abortion
338.3
Neoplasm related pain
795.89
Other abnormal tumor markers
625.9
Pelvic pain, female
640.00
Threatened abortion
HEPATITIS PANEL, ACUTE
789.00
Abdominal pain, unspecified
794.8
Abnormal liver scan
783.1
Abnormal weight gain
783.21
Abnormal weight loss
783.0
Anorexia
571.5
Cirrhosis of liver,unspecified
790.4
Elevated transaminase or LDH
573.3
Hepatitis, unspecified
789.1
Hepatomegaly
782.4
Jaundice, not of newbown
V72.85 Liver transplant recipient evaluation
789.61
Localized tenderness (RUQ)
787.01
Nausea and vomiting
780.79
Other malaise and fatigue
070.9
Viral hepatitis, unspecified
HIV
783.21
Abnormal loss of weight
786.4
Abnormal sputum
285.9
Anemia, unspecified
112.9
Candidiasis, site unspecified
682.9
Cellulitis, unspecified site
786.2
Cough
294.8
Dementia
787.91
Diarrhea
780.60
Fever, unspecified
780.79
Malaise and fatigue
263.9
Malnutrition, unspecified
486
Pneumonia, unspecified
070.9
Viral hepatitis, unspecified
HIV Viral Load
042
HIV disease
V08
Asymptomatic HIV infection status
079.53
HIV Type 2
IRON & FERRITIN
280.9
Anemia, iron deficient, unspecified
285.9
Anemia, unspecified
281.9
Anemia, unspecified deficiency
427.31 Atrial fibrillation
428.0
Congestive Heart Failure (CHF)
250.00 Diabetes mellitus, unspecified
263.9
Malnutrition, unspecified
790.6
Other abnormal blood chemistry
586
Renal failure, unspecified
070.9
Viral hepatitis, unspecified
533.90 Peptic ulcer, unspecifiec
570
Necrosis of the liver
704.00 Hair loss
V08
Asymptomatic HIV infection status
V12.3
Hx of anemia
V12.1
Hx of nutirtional deficiency
790.4
Elevated transaminase or LDH
LIPID AND CHOLESTEROL
585.9
Chronic renal failure, unspecified
428.0
Congestive Heart failure (CHF)
414.00 Coronary atherosclerosis (CAD)
250.00 Diabetes mellitus, unspecified
272.4
Hyperlipidemia, unspecified
401.9
Hypertension, essential, unspecified
244.9
Hypothyroidism
V58.69 Long term (current) use of other meds
263.9
Malnutrition, unspecified
278.00 Obesity
V81.2
Screening for unspec cardiovascular
condition (allowed 1x every 5years)
NTX - Collagen Cross Links
242.90 Hyperthyroidism
V58.69 Long term(current)use of other meds
733.00 Osteoporosis
621.7
Postmenopausal bleeding
256.9
Unspecified ovarian dysfunction
OCCULT BLOOD; FECES SCREENING
789.00 Abdominal pain, site unspecified
783.21 Abnormal loss of weight
280.9
Anemia, Iron Deficiency
285.9
Anemia, unspecified
787.91 Diarrhea
578.9
GI bleed
V58.61 Long term (current) use of anticoags
V58.69 Long term (current) use of other meds
107
April 2013
Common ICD-9 Codes
PROSTATE SPECIFIC ANTIGEN (PSA)
600.00
BPH, Benign prostate hypertrophy
790.93
Elevated prostate specific antigen
599.70
Hematuria
185
Malignant neoplasm of prostate
788.43
Nocturia
V10.46 Personal history of prostate cancer
788.20
Retention of urine, unspecified
V76.44 Screening Code - freq limitation
602.9
Unspecified disorder of prostate
601.9
Unspecified prostatitis
788.63
Urgency of urination
788.41
Urinary frequency
788.30
Urinary incontinence, unspecified
599.60
Urinary obstruction, unspecified
PROTHROMBIN TIME (PT)
790.92
Abnormal coagulation profile
427.31
Atrial fibrillation
434.91
Cerebrovascular accident (CVA)
THYROID TESTING
783.21 Abnormal loss of weight
783.1
Abnormal weight gain
331.0
Alzheimer's disease
285.9
Anemia, unspecified
300.00 Anxiety, unspecified
427.31 Atrial fibrillation
428.0
Congestive heart failure (CHF)
564.00 Constipation, unspecified
294.8
Dementia
311
Depression
250.00 Diabetes mellitus, unspecified
780.60 Fever
240.9
Goiter, unspecified
272.4
Hyperlipidemia, unspecified
401.9
Hypertension Essential unspecified
242.90 Hyperthyroidism, unspecified
244.9
Hypothyroidism, unspecified
V58.69 Long term (current) use of other meds
585.9
Chronic renal failure, unspecified
V12.50 Circulatory Disease, unspecified
286.9
Coagulation defect, unspecified
428.0
Congestive heart failure (CHF)
414.00
Coronary atherosclerosis (CAD)
562.11
Diverticulitis of colon, w/o hemorrhage
782.3
Edema
599.70
Hematuria
V58.61 Long term (current) use of anticoags
443.9
Peripheral vascular disease, unspec
586
Renal failure, unspecified
786.05
Shortness of breath
780.2
Syncope and collapse
453.9
Thrombosis of unspecified site
281.9
Unspecified Deficiency Anemia
PARTIAL THROMBOPLASTIN TIME (PTT)
427.31
Atrial fibrillation
786.50
Chest pain, unspecified
585.9
Chronic renal failure, unspecified
571.5
Cirrhosis of the liver, unspecified
286.9
Coagulation defects, unspecified
428.0
Congestive heart failure (CHF)
820.8
Fracture, hip
599.70
Hematuria
V58.61 Long term (current) use of anticoags
786.05
Shortness of breath
780.2
Syncope
780.79 Malaise and fatigue
780.93 Memory Loss
782.0
Numbness
785.1
Palpitations
290.0
Senile dementia, uncomplicated
URINE CULTURE
789.00 Abdominal pain, unspecified
724.5
Backache, unspecified
790.7
Bacteremia
585.9
Chronic renal failure, unspecified
780.60 Fever
599.70 Hematuria
V58.69 Long term (current) use of other meds
780.93 Memory loss
780.97 Mental status changes
791.9
Nonspecific findings on exam of urine
780.79 Other malaise and fatigue
038.9
Septicemia, unspecified
599.0
Urinary tract infection
VITAMIN D
579.0
Celiac disease
585.3 - Chronic kidney disease (Stage III through
585.6
275.42 Hypercalcemia
252.00 Hyperparathyroidism, unspecified
733.00 Osteoporosis unspecified
571.9
Unspecified chronic liver disease
268.9
Unspecified vitamin D deficiency
108
April 2013