2013 Billing Guide For questions or more information, please contact your Billing Coordinator PAML 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 Regence Vitamin D Limitations 14-17 Premera Vitamin D Limitations 18-22 United Healthcare Hepatitis Screening Limitations.... 23-28 Washington DSHS Guidelines 29-30 Medicare Coverage Limitation Resources 31-38 NCD-LCD Test Code & Price List Investigation Test Code & Price List Frequency Test List Always Non-Covered ICD9-CM Codes Medicare NCD & LCD Table of Contents ..39-40 Medicare NCD & LCD Listings .41-129 Common ICD-9 Codes ....130-132 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. PAML 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. PAML 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, PAML provides ABN assistance through our website www.paml.com which will help the physician's staff to determine whether an ABN is required. In addition, PAML 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.' PAML provides ABN assistance through our website www.paml.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 Regence Billing 14 April 2013 Vitamin D Limitations, Regence Billing Regence has implemented a VITAMIN D testing policy and has greatly reduced the number of ICD9 codes that they will now cover. This is effective September 1, 2011. 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. Regence's VITAMIN D 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. If a VITAMIN D test is ordered for a reason that is not considered “medically necessary” by Regence, the “Non-covered Services Waiver Form” must be provided to and signed by the patient. A list of Regence approved codes for VITAMIN D testing is provided below. REGENCE SUMMARY OF ALLOWED DX CODES FOR VITAMIN D TESTING: CPT 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed APPENDIX I - ALLOWED FOR CPT 82306 AS OF 9/1/11 Conditions Specifically Associated with Vitamin D Deficiency 252.00-252.08 Hyperparathyroidism 252.1 Hypoparathyroidism 263.9 Protein-calorie malnutrition 268.2 Osteomalacia 275.41 Hypocalcemia 275.42 Hypercalcemia 276.3 Disorders of phosphorus metabolism 278.4 Hypervitaminosis D 268.0, 268.1 Rickets 275.40, 275.49 Disorder of calcium metabolism 571.9 Chronic liver disease without alcohol 579.0 Celiac disease 579.2 Blind loop syndrome 579.4 Pancreatic Steatorrhea 579.9 Intestinal malabsorption 585.6 End stage renal disease 585.9 Chronic kidney disease 592.0 Calculus of kidney 15 April 2013 Vitamin D Limitations, Regence Billing Calculus of ureter Osteoporosis Hypocalcemia and hypomagnesemia of newborn Osteopetrosis 592.1 733.00 775.4 786.2 As a reminder, effective September 1, the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes are considered not medically necessary and denied as a provider write-off when billed with CPT 82306: ICD 9-CM and Description - NOT ALLOWED FOR 82306 or 82652 AS OF 9/1/11 780 General Symptoms V70-V77.1 Persons without reported diagnosis encountered during examination and V77.3-V77.8 Same as above V77.91 Same as above V78-V82.9 Same as above CPT 82652 Vitamin D; 1,25 dihydroxy, includes fraction(s), if performed Vitamin D policy diagnoses expanded for CPT 82652 (1,25[OH]2D) Based upon recent additional feedback received from clinicians related to CPT 82652 Vitamin D; 1, 25-dihydroxy, includes fraction(s), if performed, we have expanded the medical conditions list where we will consider serum testing for calcitriol (1,25[OH]2D) medically necessary for diagnosis or direct treatment. Effective October 1, the covered medical conditions include: ICD 9-CM and Description - ALLOWED FOR 82652 AS OF 10/1/11 135* Sarcoidosis* New code added October 1. 252.00-252.08 Hyperparathyroidism, range 252.1 Hypoparathyroidism 268.0 Rickets, active 268.1 Rickets, late effect 268.2 Osteomalacia, unspecified 270.0* Fanconi syndrome* New code added October 1. 275.3* Familial hypophosphatemia* New code added October 1. 275.40 Unspecified disorder of calcium metabolism 275.41 Hypocalcemia 275.42 Hypocalcemia 275.49 Other disorders of calcium metabolism 592.0 Calculus of kidney 592.1 Calculus of ureter 592.9 Urinary calculus, unspecified 775.4 Hypocalcemia and hypomagnesemia of newborn 16 April 2013 Vitamin D Limitations, Regence Billing 17 April 2013 Premera Billing 18 April 2013 Vitamin D Limitations, Premera Billing Premera has implemented a VITAMIN D testing policy and has greatly reduced the number of ICD9 codes that they will now cover. This is effective November 12, 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. Premera's VITAMIN D 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. Premera’s policy can be reviewed in its entirety at: https://www.premera.com/stellent/groups/public/documents/medicalpolicy/cmi_134366.ht m#P34_328 If a VITAMIN D test is ordered for a reason that is not considered “medically necessary” by Regence, the “Non-covered Services Waiver Form” must be provided to and signed by the patient. A list of Premera approved codes for VITAMIN D testing is provided below. PREMERA SUMMARY OF ALLOWED DX CODES FOR VITAMIN D TESTING: CPT 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed ICD9-CM ALLOWED FOR CPT 82306 AS OF 11/12/12 010.00 –018.96 Tuberculous infection, code range Sarcoidosis 135 200.00 –200.08 Reticulosarcoma 200.10 –200.18 Lymphosarcoma 200.20 –200.28 Burkitt’s tumor or lymphoma 200.30 –200.38 Marginal zone lymphoma 200.40 –200.48 Mantel cell lymphoma 200.50 –200.58 Primary central nervous system lymphoma 200.60 –200.68 Anaplastic large cell lymphoma 200.70 –200.78 Large cell lymphoma 200.80 –200.88 Other lymphoma variants 201.00 –201.08 Hodgkin’s paragranuloma 201.10 –201.18 Hodgkin’s granuloma 201.20 –201.28 Hodgkin’s sarcoma 201.40 –201.48 Lymphocytic-histiocytic predominance 201.50 –201.58 Nodular sclerosis 201.60 –201.68 Mixed cellularity 19 April 2013 Vitamin D Limitations, Premera Billing 201.70 –201.78 201.90 –201.98 202.00 –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 –202.98 252.00 – 252.08 252.1 262 263.0 263.1 263.9 268.0 268.1 268.2 268.9 270.0 –270.9 275.3 275.40 275.41 275.42 278.4 278.8 278.8 359.5 414.00 414.01 414.05 414.06 414.3 555.0-555.9 571.2 571.5 571.6 576.8 Lymphocytic depletion Hodgkin’s disease, unspecified Nodular lymphoma Mycosis Fungoides Sezary’s disease Malignant histiocytosis Leukemic reticuloendotheliosis Letterer-Siwe disease Malignant mast cell tumors Peripheral T-cell lymphoma Other lymphomas Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue Hyperparathyroidism, code range Hypoparathyroidism Other severe, protein-calorie malnutrition Malnutrition of moderate degree Malnutrition of mild degree Unspecified protein-calorie malnutrition Rickets, active Ricketts, late effect Osteomalacia, unspecified Unspecified vitamin D deficiency Disorders of amino-acid transport and metabolism, code range Disorders of phosphorus metabolism Disorder of calcium metabolism, unspecified Hypocalcemia Hypercalcemia Hypervitaminosis D Hyperalimentation Other hyperalimentation Myopathy in endocrine diseases Coronary atherosclerosis of unspec type of vessel, native or graft Coronary atherosclerosis of native coronary artery Coronary atherosclerosis of unspec. type of bypass graft Coronary atherosclerosis of native coronary artery of transplanted heart Coronary atherosclerosis due to lipid rich plaque Regional enteritis, code range Alcoholic cirrhosis of liver Cirrhosis of liver without mention of alcohol Biliary cirrhosis Other specified disorders of biliary tract 20 April 2013 Vitamin D Limitations, Premera Billing Intestinal malabsorption 579.0-579.9 Chronic kidney disease, code range 585.3–585.6 Chronic kidney disease, unspecified 585.9 Renal osteodystrophy 588.0 Calculus of kidney 592.0 Calculus of ureter 592.1 Urinary calculus unspecified 592.9 Calculus in diverticulum of bladder 594.0 Other calculus in bladder 594.1 Calculus in urethra 594.2 Other lower urinary tract calculus 594.8 Calculus of lower urinary tract, unspecified 594.9 Other psoriasis 696.1 Systemic lupus erythematosus 710.0 Dermatomyositis 710.3 Myalgia and myositis unspecified 729.1 Osteoporosis, unspecified 733.00 Senile osteoporosis 733.01 Idiopathic osteoporosis 733.02 Disuse osteoporosis 733.03 Other osteoporosis 733.09 Disorder of bone and cartilage unspecified 733.90 Osteogenesis imperfecta 756.51 Osteopetrosis 756.52 Hypocalcemia and hypomagnesemia of newborn 775.4 Long-term (current) use of steroids * V58.65 Long-term (current) use of other medications * V58.69 * NOTE: Report with 268.2, Osteomalacia, unspecified CPT 82652 Vitamin D; 1,25 dihydroxy, includes fraction(s), if performed ICD9-CM ALLOWED FOR CPT 82652 AS OF 11/12/12 010.00 –018.96 Tuberculous infection, code range 135 Sarcoidosis 252.00 – 252.08 Hyperparathyroidism, code range 252.1 Hypoparathyroidism Rickets, active 268.0 Ricketts, late effect 268.1 Osteomalacia, unspecified 268.2 Fanconi syndrome 270.0 Disorders of phosphorus metabolism 275.3 Disorder of calcium metabolism, unspec 275.40 21 April 2013 Vitamin D Limitations, Premera Billing 275.41 278.8 585.3–585.6 592.0 592.1 592.9 756.51 756.52 775.4 Hypocalcemia Hyperalimentation Chronic kidney disease, code range Chronic kidney disease, code range Calculus of ureter Urinary calculus unspecified Osteogenesis imperfecta Osteopetrosis Hypocalcemia & hypomagnesemia of newborn 22 April 2013 United Healthcare (UHC) Billing 23 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) 24 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 25 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 26 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 27 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 28 April 2013 Washington Public Assistance/DSHS Billing 29 April 2013 Guidelines, Washington Public Assistance/DSHS Preventative Physicals: DSHS only covers preventative physicals for children up to the age of 18. DSHS does not cover preventative physicals for adults. Family Planning Only Coverage: DSHS will only cover services associated with contraception (ICD-9 codes V25.0-V25.9, except V25.3). Pap Smears: DSHS will cover one routine Pap smear per patient, per calendar year. DSHS considers routine Pap smears to be those billed with an ICD-9 code of V76.2, V72.31, V76.47, or V25.40 - V25.49. “Screening” Testing: DSHS does not cover screening lab work. Therefore, an actual diagnosis or symptom ICD-9 code must be provided for all lab work to prove medical necessity. Monitoring Patient Medications: If monitoring the patient’s medication, the “med monitoring” ICD-9 codes (V58.61 - V58.69) are to be used as secondary diagnosis codes only. Per DSHS, the reason for the medication use must be given as the primary ICD-9 code. Prenatal Care: If a patient is being seen for prenatal care , and lab work is ordered, the diagnosis codes V22.0 (patient’s 1st pregnancy) & V22.1 (any subsequent pregnancy) are acceptable per DSHS, but V22.2 is not. HIV tests: DSHS only covers following ICD-9 codes: 042 - Human immunodeficiency virus (HIV) 079.53 - Human immunodeficiency virus, type 2 (HIV-2) V01.79 - Contact or exposure to other viral diseases V08 - Asymptomatic HIV infection status V22.0, V22.1- Pregnancy V28.89-Other Specified Antenatal Screening References All of the above information can be found in the Billing Instructions for Physician-Related Services. This is available online at: http://hrsa.dshs.wa.gov/billing/documents/provideroneguide/providerone_billing_and_resource_gui de.pdf 30 April 2013 Medicare Coverage Limitation Resources 31 April 2013 NATIONAL COVERAGE DECISION AND LOCAL COVERAGE DECISION TEST LIST AND PRICES Workpar AFP BTNP CA125 CA15-3 CA19-9 CA27.29 CBC CEA PAP SMEARS CHO UA.ID CURNNS Multiple DIF DIG DLDL FERR FREE T4 FRUCTO Multiple GGT Description Alpha Feto-protein B-Type Natriuretic Peptide CA125 CA15-3 CA19-9 CA27-29 CBC (All complete Blood Counts) CEA Cervical Smears Cholesterol Culture, Organism ID Culture Urine Colony Count Cytogenetics Studies, All Differential (Blood Counts), Manual Digoxin Direct LDL Ferritin Free T4 Fructosamine Genetic Testing GLU Gamma Glutamyltransferase Glucose GLHGB HCG-QUANT Glycohemoglobin HCG Quantitative HDL HCT HDL Hematocrit (Including Spun) Hemoglobin HGB CPT4 82105 (NCD) 83880 (LCD) Eff Date 11/25/2002 7/25/2011 Est Fee $ $ 86304 (NCD) 86300 (NCD) 86301 (NCD) 86300 (NCD) 85021-85028 (NCD) 82378 (NCD) 88150 (LCD) 82465 (NCD) 87088 (NCD) 87086 (NCD) 11/25/2002 11/25/2002 11/25/2002 11/25/2002 11/25/2002 $ $ $ $ $ 11/25/2002 1996 11/25/2002 11/25/2002 11/25/2002 $ 54.00 Client Services $ 11.00 $ 81.00 $ 58.00 4/1/1999 Client Services 11/25/2002 $ 11/25/2002 11/25/2002 11/25/2002 11/25/2002 11/25/2002 12/1/2006; 1/1/2013 $ 47.00 $ 58.00 $ 46.00 $ 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 $ 42.00 88230-88299 (LCD) 85007-85008 (NCD) 80162 (NCD) 83721 (NCD) 82728 (NCD) 84439 (NCD) 82985 (NCD) 81201, 81202, 81203, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81270, 81275, 81292 ,81293, 81294, 81295, 81296, 81297, 81298, 81299, 81317, 81318, 81319, 81381, 81401 ,81403, 81405, 81406, 88363 82977 (NCD) 82947-82948, 82962 (NCD) 83036 (NCD) 84702 / 84703 (NCD) 83718 (NCD) 85013-85014 (NCD) 85018 (NCD) 32 60.00 153.00 62.00 85.00 75.00 66.00 44.00 62.00 April 2013 NATIONAL COVERAGE DECISION AND LOCAL COVERAGE DECISION TEST LIST AND PRICES Workpar AUT Description Hemogram, Automated Eff Date 11/25/2002 Est Fee $ HEPACU 12HIVR Hepatitis Panel, Acute HIV (Virology Serology) CPT4 85021, 85027 (NCD) 80074 (NCD) 86703 (NCD) 11/25/2002 11/25/2002 $ $ 138.00 55.00 HIVQBD HIV-1 Ultrasensitive RNA 87536 (NCD) 11/25/2002 $ 355.00 HIVUS 87536 (NCD) 11/25/2002 $ 372.00 HIV2AB 1HIVWB Multiple Multiple Multiple HYPOA 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 Hypothyroid Profile 11/25/2002 11/25/2002 11/25/2002 11/25/2002 11/25/2002 11/25/2002 $ 389.00 $ 245.00 Client Services Client Services Client Services $ 133.00 Multiple IPHEN Flow Cytometry 4/10/1997 Client Services IRON.BIND IRN LIPID B.NTX OC.BLD PTT Iron Binding Capacity Iron, Total Lipid Profile N-Telopeptides (NTX) Occult Blood Partial Thromboplastin Time Platelet Count Prothrombin Time PSA T3 Uptake T4 by Icma Thyroid Profile 86702 (NCD) 86689 (NCD) 87538 (NCD) 87538 (NCD) 87539 (NCD) 84479,84436, 84443 (NCD) 88180, 88182 (LCD) 83550 (NCD) 83540 (NCD) 80061 (NCD) 82523 (NCD) 82270 (NCD) 85730 (NCD) 11/25/2002 11/25/2002 11/25/2002 11/25/2002 11/25/2002 11/25/2002 $ $ $ $ $ $ 40.00 40.00 44.00 116.00 55.00 41.00 PLT PT PSA T3UP T4 BTB TRANSFERRIN TRIG TSH VDOH VITD23 WBC Transferrin Triglycerides TSH Vitam D, 25-Hydroxy Vitamin D2/D3, 25Hydroxy Vitamin D (1, 25DiHydroxy White Cell Count Reviewed: April 2013 VIDD 42.00 85595 (NCD) 85610 (NCD) 84153 (NCD) 84479 (NCD) 84436 (NCD) 84479, 84436 (NCD) 84466 (NCD) 84478 (NCD) 84443 (NCD) 82306 (LCD) 82306 (LCD) 11/25/2002 11/25/2002 11/25/2002 11/25/2002 11/25/2002 11/25/2002 $ $ $ $ $ $ 42.00 41.00 54.00 45.00 44.00 89.00 11/25/2002 11/25/2002 11/25/2002 11/14/2011 11/14/2011 $ $ $ $ $ 62.00 11.00 45.00 88.00 186.00 82652 (LCD) 11/14/2011 $ 128.00 85048 (NCD) 11/25/2002 $ 42.00 33 April 2013 INVESTIGATIONAL TEST LIST AND PRICES: REQUIRE ABN EVERY TIME THEY ARE ORDERED Workpar 21HYAB CPT4 83519 Eff Date Investigational Est Fee $ 222.00 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 Description 21 Hydroxylase Antibodies Apolipoprotein A & B ADH Arginine Vasopressing Hormone ADIPA Adiponectin C2 C2 Complement Component C3AL C3AL C7SP Complement Component C7 C9CSP Complement Component C9 CAMPAB Campylobacter Jejuni Antibody IMMCFA, NEUOXB, Cellular Function Assay TICFA Involving Stimulation EPIP4A FTABGA FTABMA FTAGMA FCORTS GM1.AB GM1ABS GM1COM HEPDAB HIST HISTP HIST-U HIV2WB INHB LPA.MAYO LEPTNA MUR MBP 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 34 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 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 35 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. 36 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 V19.0-V19.8 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 V20.0-V20.2 Health supervision of infant or child V20.31 Health supervision for newborn under 8 days old 37 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 38 April 2013 NCD & LCD WASHINGTON B 2013 NCD & LCD Washington Medicare B 39 April 2013 NCD & LCD WASHINGTON B Alpha Fetoprotein; Serum Blood Counts B-Type Natriuretic Peptide (BNP) CA125 CA 15-3/CA 27.29 CA 19-9 CEA Collagen Cross Links (NTX) Cytogenetics Digoxin Therapeutic Drug Assay(Any Source) Genetic Testing 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) Thyroid Testing Urine Culture Vitamin D 40 NCD NCD LCD NCD NCD NCD NCD NCD LCD NCD LCD NCD NCD NCD NCD NCD Page 41-42 43-47 48-49 50 51 52 53 54 55-70 71-73 74-79 80-83 84-85 86-89 90 91 NCD NCD NCD NCD NCD NCD NCD NCD NCD NCD LCD 92-95 96 97-100 101-103 104-106 107 108-115 116-121 122-125 126-127 128-129 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 41 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 42 AFP (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*** 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 43 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 44 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 45 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 46 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 47 CBC (NCD) B-TYPE NATRIURETIC PEPTIDE (BNP) Medicare B Medical Policy July 25, 2011 CPT: 83880 Natriuretic peptide 402.01 402.11 402.91 404.01 Malignant hypertensive heart disease with heart failure Benign hypertensive heart disease with heart failure Unspecified hypertensive heart disease with heart failure Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I-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 True posterior wall infarction subsequent episode of care Subendocardial infarction subsequent episode of care Acute myocardial infarction of other specified sites subsequent episode of care Acute myocardial infarction of unspecified site subsequent episode of care Constrictive pericarditis Other primary cardiomyopathies Congestive heart failure unspecified Left heart failure Unspecified systolic heart failure Acute systolic heart failure Chronic systolic heart failure Acute on Chronic systolic heart failure Unspecified diastolic heart failure Acute diastolic heart failure Chronic diastolic heart failure Acute on Chronic diastolic heart failure Unspecified combined systolic and diastolic heart failure Acute combined systolic and diastolic heart failure Chronic combined systolic and diastolic heart failure Acute on chronic combined systolic and diastolic heart failure Heart failure unspecified Obstructive chronic bronchitis with (acute) exacerbation Obstructive chronic bronchitis with acute bronchitis Chronic obstructive asthma with (acute) exacerbation Asthma unspecified with (acute) exacerbation Acute bronchospasm Respiratory abnormality unspecified Orthopnea Shortness of breath 404.03 404.11 404.13 404.91 404.93 410.62 410.72 410.82 410.92 423.2 425.4 428.0 428.1 428.20 428.21 428.22 428.23 428.30 428.31 428.32 428.33 428.40 428.41 428.42 428.43 428.9 491.21 491.22 493.22 493.92 519.11 786.00 786.02 786.05 48 BNP (LCD) B-TYPE NATRIURETIC PEPTIDE (BNP) Medicare B Medical Policy July 25, 2011 786.06 786.07 786.09 Tachypnea Wheezing Respiratory abnormality other Reviewed: April 2013 49 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 50 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 51 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 52 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 53 CEA (NCD) 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 54 COLLAGEN CROSS LINKS NTX (NCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 CPT: CPT: CPT: CPT: CPT: CPT: CPT: CPT: CPT: CPT: 88120 88121 88230 88233 88235 88237 88239 88240 88241 88245 CPT: 88248 CPT: 88249 CPT: CPT: CPT: CPT: CPT: 88261 88262 88263 88264 88267 CPT: 88269 CPT: 88271 CPT: 88272 CPT: 88273 CPT: CPT: CPT: CPT: CPT: CPT: CPT: CPT: 88274 88275 88280 88283 88285 88289 88291 88299 171.9* 188.0-188.8 189.0 200.00 200.01 200.02 200.03 200.04 200.05 200.06 200.07 200.08 200.10 200.11 Cytp urine 3-5 probes each specimen Cytp urine 3-5 probes cmptr Tissue culture for non-neoplastic disorders; lymphocyte Skin or other solid tissue biopsy Amniotic fluid or chronic villus cells Bone marrow, blood cells Solid tumor Cryopreservation, freezing and storage of cells, each cell line Thawing and expansion of frozen cells, each aliquot Chromosome analysis for breakage syndromes; baseline Sister Chromatid Exchange (SCE), 20-25 cells Baseline breakage, score 50-100 cells, count 20 cells, 2 karyotypes (e.g. for ataxia telagiectasia, Fanconi anemia, fragile X) Chromosome analysis for breakage syndromes; score 100 cells, clastogen stress (e.g., diepoxbutane, mitomycin C, ionizing radiation, UV radiation) Chromosome analysis; count 5 cells, 1 karyotype, with banding Count 15-20 cells, 2 karyotypes, with banding Count 45 cells for mosaicism, 2 karyotypes, with banding Analyze 20-25 cells Chromosome analysis, amniotic fluid or chronic villus, count 15 cells, 1 karyotype, with banding Chromosome analysis, in situ for amniotic fluid cells, count cells from 6-12 colonies, 1 karyotype, with banding Molecular cytogenetics; DNA probe, each (e.g., FISH) Chromosomal in situ hybridization, analyze 3-5 cells (e.g. for derivatives and markers) Chromosomal in situ hybridization, analyze 10-30 cells (e.g., for microdeletions) Interface in situ hybridization, analyze 25-99 cells Interphase in situ hybridization, analyze 100-300 cells Chromosome analysis; additional karyotypes, each study Additional specialized banding technique (e.g., NOR, C-banding) Additional cells counted, each study Additional high resolution study Cytogenetics and molecular cytogenetics, interpretation and report Unlisted cytogenetic study Malignant neoplasm of connective and other soft tissue site unspecified Malignant neoplasm of the bladder Malignant neoplasm of kidney except pelvis Reticulosarcoma unspecified site Reticulosarcoma involving lymph nodes of head face and neck Reticulosarcoma involving intrathoracic lymph nodes Reticulosarcoma involving intra-abdominal lymph nodes Reticulosarcoma involving lymph nodes of axilla and upper limb Reticulosarcoma involving lymph nodes of inguinal region and lower limb Reticulosarcoma involving intrapelvic lymph nodes Reticulosarcoma involving spleen Reticulosarcoma involving lymph nodes of multiple sites Lymphosarcoma unspecified site Lymphosarcoma involving lymph nodes of head face and neck 55 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 200.12 200.13 200.14 200.15 200.16 200.17 200.18 200.20 200.21 200.22 200.23 200.24 200.25 200.26 200.27 200.28 200.80 200.81 200.82 200.83 200.84 200.85 200.86 200.87 200.88 201.00 201.01 201.02 201.03 201.04 201.05 201.06 201.07 201.08 201.10 201.11 201.12 201.13 201.14 201.15 201.16 201.17 Lymphosarcoma involving intrathoracic lymph nodes Lymphosarcoma involving intra-abdominal lymph nodes Lymphosarcoma involving lymph nodes of axilla and upper limb Lymphosarcoma involving lymph nodes of inguinal region and lower limb Lymphosarcoma involving intrapelvic lymph nodes Lymphosarcoma involving spleen Lymphosarcoma involving lymph nodes of multiple sites Burkitt's tumor or lymphoma unspecified site Burkitt's tumor or lymphoma involving lymph nodes of head face and neck Burkitt's tumor or lymphoma involving intrathoracic lymph nodes Burkitt's tumor or lymphoma involving intra-abdominal lymph nodes Burkitt's tumor or lymphoma involving lymph nodes of axilla and upper limb Burkitt's tumor or lymphoma involving lymph nodes of inguinal region and lower limb Burkitt's tumor or lymphoma involving intrapelvic lymph nodes Burkitt's tumor or lymphoma involving spleen Burkitt's tumor or lymphoma involving lymph nodes of multiple sites Other named variants of lymphosarcoma and reticulosarcoma unspecified Other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of head face and neck Other named variants of lymphosarcoma and reticulosarcoma involving intrathoracic lymph nodes Other named variants of lymphosarcoma and reticulosarcoma involving intraabdominal lymph nodes Other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of axilla and upper limb Other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of inguinal region and lower limb Other named variants of lymphosarcoma and reticulosarcoma involving intrapelvic lymph nodes Other named variants of lymphosarcoma and reticulosarcoma involving Other named variants of lymphosarcoma and reticulosarcoma involving lymph nodes of multiple sites Hodgkin's paragranuloma unspecified site Hodgkin's paragranuloma involving lymph nodes of head face and neck Hodgkin's paragranuloma involving intrathoracic lymph nodes Hodgkin's paragranuloma involving intra-abdominal lymph nodes Hodgkin's paragranuloma involving lymph nodes of axilla and upper limb Hodgkin's paragranuloma involving lymph nodes of inguinal region and lower limb Hodgkin's paragranuloma involving intrapelvic lymph nodes Hodgkin's paragranuloma involving spleen Hodgkin's paragranuloma involving lymph nodes of multiple sites Hodgkin's granuloma unspecified site Hodgkin's granuloma involving lymph nodes of head face and neck Hodgkin's granuloma involving intrathoracic lymph nodes Hodgkin's granuloma involving intra-abdominal lymph nodes Hodgkin's granuloma involving lymph nodes of axilla and upper limb Hodgkin's granuloma involving lymph nodes of inguinal region and lower Hodgkin's granuloma involving intrapelvic lymph nodes Hodgkin's granuloma involving spleen 56 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 201.18 201.20 201.21 201.22 201.23 201.24 201.25 201.26 201.27 201.28 201.40 201.41 201.42 201.43 201.44 201.45 201.46 201.47 201.48 201.50 201.51 201.52 201.53 201.54 201.55 201.56 201.57 201.58 201.60 201.61 201.62 201.63 201.64 201.65 201.66 201.67 201.68 201.70 201.71 Hodgkin's granuloma involving lymph nodes of multiple sites Hodgkin's sarcoma unspecified site Hodgkin's sarcoma involving lymph nodes of head face and neck Hodgkin's sarcoma involving intrathoracic lymph nodes Hodgkin's sarcoma involving intra-abdominal lymph nodes Hodgkin's sarcoma involving lymph nodes of axilla and upper limb Hodgkin's sarcoma involving lymph nodes of inguinal region and lower limb Hodgkin's sarcoma involving intrapelvic lymph nodes Hodgkin's sarcoma involving spleen Hodgkin's sarcoma involving lymph nodes of multiple sites Hodgkin's disease lymphocytic-histiocytic predominance unspecified site Hodgkin's disease lymphocytic-histiocytic predominance involving lymph nodes of head face and neck Hodgkin's disease lymphocytic-histiocytic predominance involving intrathoracic lymph nodes Hodgkin's disease lymphocytic-histiocytic predominance involving intraabdominal lymph nodes Hodgkin's disease lymphocytic-histiocytic predominance involving lymph nodes of axilla and upper limb Hodgkin's disease lymphocytic-histiocytic predominance involving lymph nodes of inguinal region and lower limb Hodgkin's disease lymphocytic-histiocytic predominance involving intrapelvic lymph nodes Hodgkin's disease lymphocytic-histiocytic predominance involving spleen Hodgkin's disease lymphocytic-histiocytic predominance involving lymph nodes of multiple sites Hodgkin's disease nodular sclerosis unspecified site Hodgkin's disease nodular sclerosis involving lymph nodes of head face and Hodgkin's disease nodular sclerosis involving intrathoracic lymph nodes Hodgkin's disease nodular sclerosis involving intra-abdominal lymph nodes Hodgkin's disease nodular sclerosis involving lymph nodes of axilla and upper limb Hodgkin's disease nodular sclerosis involving lymph nodes of inguinal region and lower limb Hodgkin's disease nodular sclerosis involving intrapelvic lymph nodes Hodgkin's disease nodular sclerosis involving spleen Hodgkin's disease nodular sclerosis involving lymph nodes of multiple sites Hodgkin's disease mixed cellularity unspecified site Hodgkin's disease mixed cellularity involving lymph nodes of head face and Hodgkin's disease mixed cellularity involving intrathoracic lymph nodes Hodgkin's disease mixed cellularity involving intra-abdominal lymph nodes Hodgkin's disease mixed cellularity involving lymph nodes of axilla and upper limb Hodgkin's disease mixed cellularity involving lymph nodes of inguinal region and lower limb Hodgkin's disease mixed cellularity involving intrapelvic lymph nodes Hodgkin's disease mixed cellularity involving spleen Hodgkin's disease mixed cellularity involving lymph nodes of multiple sites Hodgkin's disease lymphocytic depletion unspecified site Hodgkin's disease lymphocytic depletion involving lymph nodes of head face and neck 57 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 201.72 201.73 201.74 201.75 201.76 201.77 201.78 201.90 201.91 201.92 201.93 201.94 201.95 201.96 201.97 201.98 202.00 202.01 202.02 202.03 202.04 202.05 202.06 202.07 202.08 202.80 202.81 202.82 202.83 202.84 202.85 202.86 202.87 202.88 202.90 202.91 202.92 202.93 202.94 Hodgkin's disease lymphocytic depletion involving intrathoracic lymph nodes Hodgkin's disease lymphocytic depletion involving intra-abdominal lymph Hodgkin's disease lymphocytic depletion involving lymph nodes of axilla and upper limb Hodgkin's disease lymphocytic depletion involving lymph nodes of inguinal region and lower limb Hodgkin's disease lymphocytic depletion involving intrapelvic lymph nodes Hodgkin's disease lymphocytic depletion involving spleen Hodgkin's disease lymphocytic depletion involving lymph nodes of multiple Hodgkin's disease unspecified type unspecified site Hodgkin's disease unspecified type involving lymph nodes of head face and neck Hodgkin's disease unspecified type involving intrathoracic lymph nodes Hodgkin's disease unspecified type involving intra-abdominal lymph nodes Hodgkin's disease unspecified type involving lymph nodes of axilla and upper limb Hodgkin's disease unspecified type involving lymph nodes of inguinal region and lower limb Hodgkin's disease unspecified type involving intrapelvic lymph nodes Hodgkin's disease unspecified type involving spleen Hodgkin's disease unspecified type involving lymph nodes of multiple sites Nodular lymphoma unspecified site Nodular lymphoma involving lymph nodes of head face and neck Nodular lymphoma involving intrathoracic lymph nodes Nodular lymphoma involving intra-abdominal lymph nodes Nodular lymphoma involving lymph nodes of axilla and upper limb Nodular lymphoma involving lymph nodes of inguinal region and lower limb Nodular lymphoma involving intrapelvic lymph nodes Nodular lymphoma involving spleen Nodular lymphoma involving lymph nodes of multiple sites Other malignant lymphomas unspecified site Other malignant lymphomas involving lymph nodes of head face and neck Other malignant lymphomas involving intrathoracic lymph nodes Other malignant lymphomas involving intra-abdominal lymph nodes Other malignant lymphomas involving lymph nodes of axilla and upper limb Other malignant lymphomas involving lymph nodes of inguinal region and lower limb Other malignant lymphomas involving intrapelvic lymph nodes Other malignant lymphomas involving spleen 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 head face and neck Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving intrathoracic lymph nodes Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving intra-abdominal lymph nodes Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes of axilla and upper limb 58 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 202.95 202.96 202.97 202.98 203.00 203.01 203.10 203.11 203.12 203.82 204.00 204.01 204.02 204.10 204.12 204.22 204.80 204.81 204.82 205.00 205.01 205.02 205.10 205.11 205.12 205.20 205.21 205.22 205.30 205.31 205.32 205.80 205.81 205.82 205.90 205.91 206.00 206.01 206.02 206.82 206.90 206.91 207.20 207.21 207.22 207.82 Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving lymph nodes of inguinal region and lower limb Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving intrapelvic lymph nodes Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue involving spleen 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 remission Plasma cell leukemia without remission Plasma cell leukemia in remission Plasma cell leukemia in relapse Other immunoproliferative neoplasms in relapse Lymphoid leukemia acute without mention of having achieved remission Lymphoid leukemia acute in remission Lymphoid leukemia acute in relapse Chronic lymphoid leukemia, without mention of having achiever remission Lymphoid leukemia chronic in relapse Lymphoid leukemia subacute in relapse Other lymphoid leukemia without mention of having achieved remission Other lymphoid leukemia in remission Other lymphoid leukemia in relapse Myeloid leukemia acute without mention of having achieved remission Myeloid leukemia acute in remission Myeloid leukemia subacute in relapse Myeloid leukemia chronic without mention of having achieved remission Myeloid leukemia chronic in remission Myeloid leukemia chronic in relapse Myeloid leukemia subacute without mention of having achieved remission Myeloid leukemia subacute in remission Myeloid leukemia subacute in relapse Myeloid sarcoma without mention of having achieved remission Myeloid sarcoma in remission Myeloid sarcoma in relapse Other myeloid leukemia without mention of having achieved remission Other myeloid leukemia in remission Other myeloid leukemia in relapse Unspecified myeloid leukemia without mention of having achieved remission Unspecified myeloid leukemia in remission Monocytic leukemia acute without mention of having achieved remission Monocytic leukemia acute in remission Monocytic leukemia subacute in relapse Other monocytic leukemia in relapse Unspecified monocytic leukemia without mention of having achieved Unspecified monocytic leukemia in remission Megakaryocytic leukemia without remission Megakaryocytic leukemia in remission Megakaryocytic leukemia in relapse Other specified leukemia in relapse 59 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 208.00 208.01 208.02 225.2 238.4 238.6 238.71 238.72 238.73 238.74 238.75 238.77 238.79 259.0 273.1 273.3 284.01 284.09 284.19 284.2 284.81 284.89 284.9 285.0 285.1 285.21 285.22 285.29 285.8 285.9 287.30 287.31 287.32 287.33 287.39 287.41 287.49 288.01* 288.02 288.1 288.2 288.3 288.4 288.61 288.63 288.64 288.65 288.8 289.6 289.7 289.81 Leukemia of unspecified cell type acute without mention of having achieved remission Leukemia of unspecified cell type acute in remission Leukemia of unspecified cell type acute in relapse Benign neoplasm of cerebral meninges Polycythemia vera Neoplasm of uncertain behavior of plasma cells Essential thrombocythemia Low grade myelodysplastic syndrome lesions High grade myelodysplastic syndrome lesions Myelodysplastic syndrome with 5q deletion Myelodysplastic syndrome, unspecified Post-transplant lymphoproliferative disorder (PTLD) Other lymphatic and hematopoietic tissues Delay in sexual development and puberty not elsewhere classified Monoclonal paraproteinemia Macroglobulinemia Constitutional red blood cell aplasia Other constitutional aplastic anemia Other pancytopenia Myelophthisis Red cell aplasia (acquired) (adult) (with thymoma) Other specified aplastic anemias Aplastic anemia unspecified Sideroblastic anemia Acute posthemorrhagic anemia Anemia in chronic kidney disease Anemia in neoplastic disease Anemia of other chronic illness Other specified anemias Anemia unspecified Primary thrombocytopenia, unspecified Immune thrombocytopenic purpura Evans’ syndrome Congenital and hereditary thrombocytopenic purpura Other primary thrombocytopenia Posttransfusion purpura Other secondary thrombocytopenia Congenital neutropenia Cyclic neutropenia Functional disorders of polymorphonuclear neutrophils Genetic anomalies of leukocytes Eosinophilia Hemophagocytic syndromes Lymphocytosis (symptomatic) Monocytosis (symptomatic) Plasmacytosis Basophilia Other specified disease of white blood cells Familial polycythemia Methemoglobinemia Primary hypercoagulable state 60 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 289.82 289.83 289.89 334.8 388.5 389.10 629.9 630 631.0 632 646.33 655.00 655.01 655.03 655.10 655.11 655.13 655.20 655.21 655.23 656.40 656.41 656.43 656.50 656.51 656.53 656.60 656.61 656.63 657.00 657.01 657.03 658.00 658.01 658.03 659.50 659.51 659.53 659.60 Secondary hypercoagulable state Myelofibrosis Other specified diseases of blood and blood-forming organs Other spinocerebellar diseases Disorders of acoustic nerve Sensorineural hearing loss unspecified Unspecified disorder of female genital organs Hydatidiform mole Other abnormal product of conception Missed abortion Habitual aborter antepartum condition or complication Central nervous system malformation in fetus unspecified as to episode of care in pregnancy Central nervous system malformation in fetus with delivery Central nervous system malformation in fetus antepartum Chromosomal abnormality in fetus affecting management of mother unspecified as to episode of care in pregnancy Chromosomal abnormality in fetus affecting management of mother with delivery Chromosomal abnormality in fetus affecting management of mother antepartum Hereditary disease in family possibly affecting fetus affecting management of mother unspecified as to episode of care in pregnancy Hereditary disease in family possibly affecting fetus affecting management of mother with delivery Hereditary disease in family possibly affecting fetus affecting management of mother antepartum condition or complication Intrauterine death affecting management of mother unspecified as to episode of care Intrauterine death affecting management of mother delivered Intrauterine death affecting management of mother antepartum Poor fetal growth affecting management of mother unspecified as to episode of care Poor fetal growth affecting management of mother delivered Poor fetal growth affecting management of mother antepartum condition or complication Excessive fetal growth affecting management of mother unspecified as to episode of care Excessive fetal growth affecting management of mother delivered Excessive fetal growth affecting management of mother antepartum Polyhydramnios unspecified as to episode of care Polyhydramnios with delivery Polyhydramnios antepartum complication Oligohydramnios unspecified as to episode of care Oligohydramnios delivered Oligohydramnios antepartum Elderly primigravida unspecified as to episode of care Elderly primigravida delivered Elderly primigravida antepartum Other advanced maternal age unspecified as to episode of care or not applicable 61 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 659.61 659.63 740.0 740.1 740.2 742.0 742.1 742.2 742.3 742.4 742.51 742.53 742.59 742.8 743.00 743.03 743.06 743.10 743.11 743.12 743.20 743.21 743.22 743.30 743.31 743.32 743.33 743.34 743.35 743.36 743.37 743.39 743.41 743.42 743.43 743.44 743.45 743.46 743.47 743.48 743.49 743.51 743.52 743.53 743.54 743.55 743.56 743.57 743.58 743.59 743.61 Other advanced maternal age delivered with or without antepartum condition Other advanced maternal age antepartum condition or complication Anencephalus Craniorachischisis Iniencephaly Encephalocele Microcephalus Congenital reduction deformities of brain Congenital hydrocephalus Other specified congenital anomalies of brain Diastematomyelia Hydromyelia Other specified congenital anomalies of spinal cord Other specified congenital anomalies of nervous system Clinical anophthalmos unspecified Cystic eyeball congenital Cryptophthalmos Microphthalmos unspecified Simple microphthalmos Microphthalmos associated with other anomalies of eye and adnexa Buphthalmos unspecified Simple buphthalmos Buphthalmos associated with other ocular anomalies Congenital cataract unspecified Congenital capsular and subcapsular cataract Congenital cortical and zonular cataract Congenital nuclear cataract Congenital total and subtotal cataract Congenital aphakia Congenital anomalies of lens shape Congenital ectopic lens Other congenital cataract and lens anomalies Congenital anomalies of corneal size and shape Congenital corneal opacities interfering with vision Other congenital corneal opacities Specified congenital anomalies of anterior chamber , chamber angle and related structures Aniridia Other specified congenital anomalies of iris and ciliary body Specified congenital anomalies of sclera Multiple and combined congenital anomalies of anterior segment Other congenital anomalies of anterior segment Vitreous anomalies congenital Fundus coloboma Chorioretinal degeneration congenital Congenital folds and cysts of posterior segment Congenital macular changes Other retinal changes congenital Specified congenital anomalies of optic disc Vascular anomalies congenital Other congenital anomalies of posterior segment Congenital ptosis of eyelid 62 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 743.62 743.63 743.64 743.65 743.66 743.69 743.8 743.9 744.00 744.01 744.02 744.03 744.04 744.05 744.09 744.1 744.21 744.22 744.23 744.24 744.29 744.3 744.41 744.42 744.43 744.46 744.47 744.49 744.5 744.81 744.82 744.83 744.84 744.89 744.9 745.0 745.10 745.11 745.12 745.19 745.2 745.3 745.4 745.5 745.60 745.61 745.69 745.7 745.8 745.9 746.00 746.01 Congenital deformities of eyelids Other specified congenital anomalies of eyelid Specified congenital anomalies of lacrimal gland Specified congenital anomalies of lacrimal passages Specified congenital anomalies of orbit Other congenital anomalies of eyelids lacrimal system and orbit Other specified anomalies of eye congenital Unspecified anomaly of eye congenital Unspecified congenital anomaly of ear with impairment of hearing Congenital absence of external ear Other congenital anomalies of external ear with impairment of hearing Congenital anomaly of middle ear except ossicles Congenital anomalies of ear ossicles Congenital anomalies of inner ear Other congenital anomalies of ear causing impairment of hearing Accessory auricle Absence of ear lobe congenital Macrotia Microtia Specified congenital anomalies of eustachian tube Other congenital anomalies of ear Unspecified congenital anomaly of ear Branchial cleft sinus or fistula Branchial cleft cyst Cervical auricle Preauricular sinus or fistula Preauricular cyst Other branchial cleft cyst or fistula; preauricular sinus Webbing of neck Macrocheilia Microcheilia Macrostomia Microstomia Other specified congenital anomalies of face and neck Unspecified congenital anomalies of face and neck Common truncus Complete transposition of great vessels Double outlet right ventricle Corrected transposition of great vessels Other transposition of great vessels Tetralogy of fallot Common ventricle Ventricular septal defect Ostium secundum type atrial septal defect Endocardial cushion defect unspecified type Estium primum defect Other endocardial cushion defects Cor biloculare Other bulbus cordis anomalies and anomalies of cardiac septal closure Unspecified defect of septal closure Congenital pulmonary valve anomaly unspecified Atresia of pulmonary valve congenital 63 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 746.02 746.09 746.1 746.2 746.3 746.4 746.5 746.6 746.7 746.81 746.82 746.83 746.84 746.85 746.86 746.87 746.89 746.9 747.0 747.10 747.11 747.20 747.21 747.22 747.29 747.31 747.32 747.39 747.40 747.41 747.42 747.49 747.5 747.60 747.61 747.62 747.63 747.64 747.69 747.81 747.82 747.83 747.89 747.9 748.0 748.1 748.2 748.3 748.4 748.5 748.60 748.61 Stenosis of pulmonary valve congenital Other congenital anomalies of pulmonary valve Tricuspid atresia and stenosis congenital Ebstein's anomaly Congenital stenosis of aortic valve Congenital insufficiency of aortic valve Congenital mitral stenosis Congenital mitral insufficiency Hypoplastic left heart syndrome Subaortic stenosis congenital Cor triatriatum Infundibular pulmonic stenosis congenital Congenital obstructive anomalies of heart not elsewhere classified Coronary artery anomaly congenital Congenital heart block Malposition of heart and cardiac apex Other specified congenital anomalies of heart Unspecified congenital anomaly of heart Patent ductus arteriosus Coarctation of aorta (preductal) (postductal) Interruption of aortic arch Congenital anomaly of aorta unspecified Congenital anomalies of aortic arch Congenital atresia and stenosis of aorta Other congenital anomalies of aorta Pulmonary artery coarctation and atresia Pulmonary arteriovenous malformation Congenital anomalies of pulmonary artery Congenital anomaly of great veins unspecified Total anomalous pulmonary venous connection Partial anomalous pulmonary venous connection Other anomalies of great veins Absence or hypoplasia of umbilical artery Anomaly of the peripheral vascular system unspecified site Gastrointestinal vessel anomaly Renal vessel anomaly Upper limb vessel anomaly Lower limb vessel anomaly Anomalies of other specified sites of peripheral vascular system Congenital anomalies of cerebrovascular system Spinal vessel anomaly Persistent fetal circulation Other specified congenital anomalies of circulatory system Unspecified congenital anomaly of circulatory system Choanal atresia Other congenital anomalies of nose Web of larynx Other congenital anomalies of larynx trachea and bronchus Congenital cystic lung Congenital agenesis hypoplasia and dysplasia of lung Congenital anomaly of lung unspecified Congenital bronchiectasis 64 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 748.69 748.8 748.9 749.00 749.01 749.02 749.03 749.04 749.10 749.11 749.12 749.13 749.14 749.20 749.21 749.22 749.23 749.24 749.25 750.0 750.10 750.11 750.12 750.13 750.15 750.16 750.19 750.21 750.22 750.23 750.24 750.25 750.26 750.27 750.29 750.3 750.4 750.5 750.6 750.7 750.8 750.9 751.0 751.1 751.2 751.3 751.4 751.5 751.60 751.61 751.62 751.69 Other congenital anomalies of lung Other specified congenital anomalies of respiratory system Unspecified congenital anomaly of respiratory system Cleft palate unspecified Cleft palate unilateral complete Cleft palate unilateral incomplete Cleft palate bilateral complete Cleft palate bilateral incomplete Cleft lip unspecified Cleft lip unilateral complete Cleft lip unilateral incomplete Cleft lip bilateral complete Cleft lip bilateral incomplete Cleft palate with Cleft lip unspecified Cleft palate with Cleft lip unilateral complete Cleft palate with Cleft lip unilateral incomplete Cleft palate with Cleft lip bilateral complete Cleft palate with Cleft lip bilateral incomplete Other combinations of cleft palate with cleft lip Tongue tie Congenital anomaly of tongue unspecified Aglossia Congenital adhesions of tongue Congenital fissure of tongue Macroglossia Microglossia Other congenital anomalies of tongue Congenital absence of salivary gland Accessory salivary gland Congenital atresia salivary duct Congenital fistula of salivary gland Congenital fistula of lip Other specified congenital anomalies of mouth Congenital diverticulum of pharynx Other specified congenital anomalies of pharynx Congenital tracheoesophageal fistula esophageal atresia and stenosis Other specified congenital anomalies of esophagus Congenital hypertrophic pyloric stenosis Congenital hiatus hernia Other specified congenital anomalies of stomach Other specified congenital anomalies of upper alimentary tract Unspecified congenital anomaly of upper alimentary tract Meckel's diverticulum Congenital atresia and stenosis of small intestine Congenital atresia and stenosis of large intestine rectum and anal canal Hirschsprung's disease and other congenital functional disorders of colon Congenital anomalies of intestinal fixation Other congenital anomalies of intestine Unspecified congenital anomaly of gallbladder bile ducts and liver Biliary atresia congenital Congenital cystic disease of liver Other congenital anomalies of gallbladder bile ducts and liver 65 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 751.7 751.8 751.9 752.0 752.10 752.11 752.19 752.2 752.31 752.32 752.33 752.34 752.35 752.36 752.39 752.40 752.41 752.42 752.43 752.44 752.45 752.46 752.47 752.49 752.51 752.52 752.61 752.62 752.63 752.64 752.65 752.69 752.7 752.81 752.89 752.9 753.0 753.10 753.11 753.12 753.13 753.14 753.15 753.16 753.17 753.19 753.20 753.21 753.22 753.23 753.29 753.3 Congenital anomalies of pancreas Other specified congenital anomalies of digestive system Unspecified congenital anomaly of digestive system Congenital anomalies of ovaries Unspecified congenital anomaly of fallopian tubes and broad ligaments Embryonic cyst of fallopian tubes and broad ligaments Other congenital anomalies of fallopian tubes and broad ligaments Doubling of uterus Agenesis of uterus Hypoplasia of uterus Unicornuate uterus Bicornuate uterus Septate uterus Arcuate uterus Other anomalies of uterus Unspecified congenital anomaly of cervix vagina and external female genitalia Embryonic cyst of cervix vagina and external female genitalia Imperforate hymen Cervical agenesis Vaginal duplication Vaginal agenesis Transverse vaginal septum Longitudinal vaginal septum Other congenital anomalies of cervix vagina and external female genitalia Undescended testis Retractile testis Hypospadias Epispadias Congenital chordee Micropenis Hidden penis Other penile anomalies Indeterminate sex and pseudohermaphroditism Scrotal transposition Other specified anomalies of genital organs Unspecified congenital anomaly of genital organs Renal agenesis and dysgenesis Cystic kidney disease unspecified Congenital single renal cyst Polycystic kidney unspecified type Polycystic kidney autosomal dominant Polycystic kidney autosomal recessive Renal dysplasia Medullary cystic kidney Medullary sponge kidney Other specified cystic kidney disease Unspecified obstructive defect of renal pelvis and ureter Congenital obstruction of ureteropelvic junction Congenital obstruction of ureterovesical junction Congenital ureterocele Other obstructive defect of renal pelvis and ureter Other specified anomalies of kidney 66 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 753.4 753.5 753.6 753.7 753.8 753.9 754.0 754.1 754.2 754.30 754.31 754.32 754.33 754.35 754.40 754.41 754.42 754.43 754.44 754.50 754.51 754.52 754.53 754.59 754.60 754.61 754.62 754.69 754.70 754.71 754.79 754.81 754.82 754.89 755.00 755.01 755.02 755.10 755.11 755.12 755.13 755.14 755.20 755.21 755.22 755.23 755.24 755.25 Other specified anomalies of ureter Exstrophy of urinary bladder Congenital atresia and stenosis of urethra and bladder neck Congenital anomalies of urachus Other specified congenital anomalies of bladder and urethra Unspecified congenital anomaly of urinary system Congenital musculoskeletal deformities of skull face and jaw Congenital musculoskeletal deformities of sternocleidomastoid muscle Congenital musculoskeletal deformities of spine Congenital dislocation of hip unilateral Congenital dislocation of hip bilateral Congenital subluxation of hip unilateral Congenital subluxation of hip bilateral Congenital dislocation of one hip with subluxation of other hip Genu recurvatum Congenital dislocation of knee (with genu recurvatum) Congenital bowing of femur Congenital bowing of tibia and fibula Congenital bowing of unspecified long bones of leg Congenital talipes varus Congenital talipes equinovarus Congenital metatarsus primus varus Congenital metatarsus varus Other congenital varus deformities of feet Congenital talipes valgus Congenital pes planus Talipes calcaneovalgus Other congenital valgus deformities of feet Talipes unspecified Talipes cavus Other congenital deformities of feet Pectus excavatum Pectus carinatum Other specified nonteratogenic anomalies Polydactyly unspecified digits Polydactyly of fingers Polydactyly of toes Syndactyly of multiple and unspecified sites Syndactyly of fingers without fusion of bone Syndactyly of fingers with fusion of bone Syndactyly of toes without fusion of bone Syndactyly of toes with fusion of bone Unspecified reduction deformity of upper limb congenital Transverse deficiency of upper limb Longitudinal deficiency of upper limb not elsewhere classified Longitudinal deficiency combined involving humerus radius and ulna (complete or incomplete) Longitudinal deficiency humeral complete or partial (with or without distal deficiencies incomplete) Longitudinal deficiency radioulnar complete or partial (with or without distal deficiencies incomplete) 67 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 755.26 755.27 755.28 755.29 755.30 755.31 755.32 755.33 755.34 755.35 755.36 755.37 755.38 755.39 755.4 755.5 755.51 755.52 755.53 755.54 755.55 755.56 755.57 755.58 755.59 755.60 755.61 755.62 755.63 755.64 755.65 755.66 755.67 755.69 755.8 Longitudinal deficiency radial complete or partial (with or without distal deficiencies incomplete) Longitudinal deficiency ulnar complete or partial (with or without distal deficiencies incomplete) Longitudinal deficiency carpals or metacarpals complete or partial (with or without incomplete phalangeal deficiency) Longitudinal deficiency phalanges complete or partial Unspecified reduction deformity of lower limb congenital Transverse deficiency of lower limb Longitudinal deficiency of lower limb not elsewhere classified Longitudinal deficiency combined involving femur tibia and fibula (complete or incomplete) Longitudinal deficiency femoral complete or partial (with or without distal deficiencies incomplete) Longitudinal deficiency tibiofibular complete or partial (with or without distal deficiencies incomplete) Longitudinal deficiency tibia complete or partial (with or without distal deficiencies incomplete) Longitudinal deficiency fibular complete or partial (with or without distal deficiencies incomplete) Longitudinal deficiency tarsals or metatarsals complete or partial (with or without incomplete phalangeal deficiency) Longitudinal deficiency phalanges complete or partial Congenital reduction deformities unspecified limb Unspecified anomaly of upper limb congenital Congenital deformity of clavicle Congenital elevation of scapula Radioulnar synostosis Madelung's deformity Acrocephalosyndactyly Accessory carpal bones Macrodactylia (fingers) Cleft hand congenital Other congenital anomalies of upper limb including shoulder girdle Unspecified congenital anomaly of lower limb Coxa valga congenital Coxa vara congenital Other congenital deformity of hip (joint) Congenital deformity of knee (joint) Macrodactylia of toes Other congenital anomalies of toes Congenital anomalies of foot not elsewhere classified Other congenital anomalies of lower limb including pelvic girdle Other specified congenital anomalies of unspecified limb 68 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 755.9 756.0 756.10 756.11 756.12 756.13 756.14 756.15 756.16 756.17 756.19 756.2 756.3 756.4 756.50 756.51 756.52 756.53 756.54 756.55 756.56 756.59 756.6 756.70 756.71 756.72 756.73 756.81 756.82 756.83 756.89 757.0 757.1 757.2 757.31 757.32 757.33 757.39 758.0 758.1 758.2 758.31 758.32 Unspecified congenital anomaly of unspecified limb Congenital anomalies of skull and face bones Congenital anomaly of spine unspecified Congenital spondylolysis lumbosacral region Spondylolisthesis congenital Absence of vertebra congenital Hemivertebra Fusion of spine (vertebra) congenital Klippel-feil syndrome Spina bifida occulta Other congenital anomalies of spine Cervical rib Other congenital anomalies of ribs and sternum Chondrodystrophy Congenital osteodystrophy unspecified Osteogenesis imperfecta Osteopetrosis Osteopoikilosis Polyostotic fibrous dysplasia of bone Chondroectodermal dysplasia Multiple epiphyseal dysplasia Other congenital osteodystrophies Congenital anomalies of diaphragm Anomaly of abdominal wall unspecified Prune belly syndrome Omphalocele Gastroschisis Congenital absence of muscle and tendon Accessory muscle Ehlers-danlos syndrome Other specified congenital anomalies of muscle tendon fascia and connective tissue Hereditary edema of legs Ichthyosis congenita Dermatoglyphic anomalies Congenital ectodermal dysplasia Vascular hamartomas Congenital pigmentary anomalies of skin Other specified congenital anomalies of skin Down's syndrome Patau's syndrome Edwards' syndrome Cri-du-chat syndrome Velo-cardio-facial syndrome 69 CYTOGENETICS (LCD) CYTOGENETICS Medicare B Medical Policy February 1999; Effective May 1, 2006 758.33 758.39 758.4 758.5 758.6 758.7 758.81 758.89 758.9 759.83 783.22 783.40 783.41 783.42 783.43 796.5 796.6 V13.61 V13.62 V13.63 V13.64 V13.65 V13.66 V13.67 V13.68 V13.69 V18.4 V19.5 Other microdeletions Other autosomal deletions Balanced autosomal translocation in normal individual Other conditions due to autosomal anomalies Gonadal dysgenesis Klinefelter's syndrome Other conditions due to sex chromosome anomalies Other conditions due to chromosome anomalies Conditions due to anomaly of unspecified chromosome Fragile x syndrome Underweight Unspecified lack of normal physiological development Failure to thrive Delayed milestones Short stature Abnormal finding on antenatal screening Nonspecific abnormal findings on neonatal screening Personal history of (corrected) hypospadias Personal history of other (corrected) congenital malformations of genitourinary system Personal history of (corrected) congenital malformations of nervous system Personal history of (corrected) congenital malformations of eye, ear, face and neck Personal history of (corrected) congenital malformations of heart and circulatory system Personal history of (corrected) congenital malformations of respiratory system Personal history of (corrected) congenital malformations of digestive system Personal history of (corrected) congenital malformations of integument, limbs and musculoskeletal systems Personal history of other (corrected) congenital malformations Family history of mental retardation Family history of congenital anomalies V49.89* Other specified conditions influencing health status *171.9 Medical record must contain documentation of either: alveolar soft part sarcoma, alveolar rhabdomyosarcoma, clear cell sarcoma, desmoplastic small sound cell tumor, Ewing sarcoma, myxoid liposarcoma, low grade fibromyxoid sarcoma, extra skeletal myxoid chondrosarcoma, inflammatory myofibroblastic tumor or synovial sarcoma in order to use these diagnosis codes Limited to infantile genetic agranulocytosis only To be used only when repeat testing is believed to be medically reasonable and necessary *288.01 *V49.89 Reviewed: April 2013 70 CYTOGENETICS (LCD) 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 71 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 72 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 73 DIGOXIN (NCD) GENETIC TESTING Medicare B Medical Policy December 1, 2006; updated January 1, 2013 CPT: 81201 CPT: 81202 CPT: 81203 CPT: 81211 CPT: 81212 CPT: 81213 CPT: 81214 CPT: 81215 CPT: 81216 CPT: 81217 CPT: 81270 CPT: 81275 CPT: 81292 CPT: 81293 CPT: 81294 CPT: 81295 CPT: 81296 CPT: 81297 Molecular pathology procedure, level 7 (eg, analysis of 11-25 exons by dna sequence analysis, mutation scanning or duplication/deletion variants of 2650 exons, cytogenomic array analysis for neoplasia) Examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular analysis (eg, kras mutational analysis) Apc (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [fap], attenuated fap) gene analysis; duplication/deletion variants Brca1, brca2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants in brca1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb) Brca1, brca2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; 185delag, 5385insc, 6174delt variants Brca1, brca2 (breast cancer 1 and 2) (eg, hereditary breast and ovarian cancer) gene analysis; uncommon duplication/deletion variants Brca1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14-20 del 26kb, exon 22 del 510bp, exon 8-9 del 7.1kb) Brca1 (breast cancer 1) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant Brca2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis Brca2 (breast cancer 2) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant Jak2 (janus kinase 2) (eg, myeloproliferative disorder) gene analysis, p.val617phe (v617f) variant Kras (v-ki-ras2 kirsten rat sarcoma viral oncogene) (eg, carcinoma) gene analysis, variants in codons 12 and 13 Mlh1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary nonpolyposis colorectal cancer, lynch syndrome) gene analysis; full sequence analysis Mlh1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary nonpolyposis colorectal cancer, lynch syndrome) gene analysis; known familial variants Mlh1 (mutl homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary nonpolyposis colorectal cancer, lynch syndrome) gene analysis; duplication/deletion variants Msh2 (muts homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, lynch syndrome) gene analysis; full sequence analysis Msh2 (muts homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, lynch syndrome) gene analysis; known familial variants Msh2 (muts homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, lynch syndrome) gene analysis; duplication/deletion variants 74 GENETIC TESTING (LCD) GENETIC TESTING Medicare B Medical Policy December 1, 2006; updated January 1, 2013 CPT: 81298 CPT: 81299 CPT: 81317 CPT: 81318 CPT: 81319 CPT: 81381 CPT: 81401 CPT: 81403 CPT: 81405 CPT: 81406 CPT: 88363 Msh6 (muts homolog 6 [e. coli]) (eg, hereditary non-polyposis colorectal cancer, lynch syndrome) gene analysis; full sequence analysis Msh6 (muts homolog 6 [e. coli]) (eg, hereditary non-polyposis colorectal cancer, lynch syndrome) gene analysis; known familial variants Pms2 (postmeiotic segregation increased 2 [s. cerevisiae]) (eg, hereditary nonpolyposis colorectal cancer, lynch syndrome) gene analysis; full sequence analysis Pms2 (postmeiotic segregation increased 2 [s. cerevisiae]) (eg, hereditary nonpolyposis colorectal cancer, lynch syndrome) gene analysis; known familial variants Pms2 (postmeiotic segregation increased 2 [s. cerevisiae]) (eg, hereditary nonpolyposis colorectal cancer, lynch syndrome) gene analysis; duplication/deletion variants Hla class i typing, high resolution (ie, alleles or allele groups); one allele or allele group (eg, b*57:01p), each Molecular pathology procedure, level 2 (eg, 2-10 snps, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) Molecular pathology procedure, level 4 (eg, analysis of single exon by dna sequence analysis, analysis of >10 amplicons using multiplex pcr in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) Molecular pathology procedure, level 6 (eg, analysis of 6-10 exons by dna sequence analysis, mutation scanning or duplication/ deletion variants of 1125 exons) Molecular pathology procedure, level 7 (eg, analysis of 11-25 exons by dna sequence analysis, mutation scanning or duplication/deletion variants of 2650 exons, cytogenomic array analysis for neoplasia) Examination and selection of retrieved archival (ie, previously diagnosed) tissue(s) for molecular analysis (eg, kras mutational analysis) The following Diagnosis codes billed with CPT codes 81211, 81212, 81213, 81214, 81215, 81216 and 81217 meet coverage criteria for BRCA1 and BRCA2 gene mutation testing: 158.0 Malignant neoplasm of retroperitoneum 158.8 Malignant neoplasm of specified parts of peritoneum 174.0 Malignant neoplasm of nipple and areola of female breast 174.1 Malignant neoplasm of central portion of female breast 174.2 Malignant neoplasm of upper-inner quadrant of female breast 174.3 Malignant neoplasm of lower-inner quadrant of female breast 174.4 Malignant neoplasm of upper-outer quadrant of female breast 174.5 Malignant neoplasm of lower-outer quadrant of female breast 174.6 Malignant neoplasm of axillary tail of female breast 174.8 Malignant neoplasm of other specified sites of female breast 174.9 Malignant neoplasm of breast (female) unspecified site 175.0 Malignant neoplasm of nipple and areola of male breast 175.9 Malignant neoplasm of other and unspecified sites of male breast 75 GENETIC TESTING (LCD) GENETIC TESTING Medicare B Medical Policy December 1, 2006; updated January 1, 2013 183.0 183.2 233.0 V10.3 V10.43 Malignant neoplasm of ovary Malignant neoplasm of fallopian tube Carcinoma in situ of breast Personal history of malignant neoplasm of breast Personal history of malignant neoplasm of ovary CPT codes 81201, 81202, 81203, 81275, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81403, 81405, 81406 and 88363 when billed with the following diagnosis codes meet coverage criteria for hereditary colorectal cancer (HNPCC) including endometrial and/or ovarian cancer when the latter two are reasonably considered as part of the Lynch syndrome, Familial Adenomatous Polyposis (FAP) testing as well as for KRAS testing, when such testing is used to determine suitability of the use of either erbitux or panitumumab within the limitations noted above: 153.0 Malignant neoplasm of hepatic flexure 153.1 Malignant neoplasm of transverse colon 153.2 Malignant neoplasm of descending colon 153.3 Malignant neoplasm of sigmoid colon 153.4 Malignant neoplasm of cecum 153.5 Malignant neoplasm of appendix vermiformis 153.6 Malignant neoplasm of ascending colon 153.7 Malignant neoplasm of splenic flexure 153.8 Malignant neoplasm of other specified sites of large intestine 153.9 Malignant neoplasm of colon unspecified site 154.0 Malignant neoplasm of rectosigmoid junction 154.1 Malignant neoplasm of rectum 154.2 Malignant neoplasm of anal canal 154.3 Malignant neoplasm of anus unspecified site 154.8 Malignant neoplasm of other sites of rectum rectosigmoid junction and anus 179 Malignant neoplasm of uterus-part uns 182.8 Malignant neoplasm of other specified sites of body of uterus 183.0 Malignant neoplasm of ovary 183.2 Malignant neoplasm of fallopian tube 197.5 Secondary malignant neoplasm of large intestine and rectum V10.05 Personal history of malignant neoplasm of large intestine V10.06 Personal history of malignant neoplasm of rectum rectosigmoid junction and anus V10.42 Personal history of malignant neoplasm of other parts of uterus V12.72 Personal history of colonic polyps ***should be used to denote any of the polyposis conditions as described under indications and limitations above The following diagnosis codes when billed with CPT codes 81270 and 81403 meet coverage criteria for JAK2 testing: 204.00 Acute lymphoid leukemia, without mention of having achieved remission 204.10 Chronic lymphoid leukemia, without mention of having achieved remission 204.11 Lymphoid leukemia chronic in remission 76 GENETIC TESTING (LCD) GENETIC TESTING Medicare B Medical Policy December 1, 2006; updated January 1, 2013 204.12 205.00 205.10 238.4 238.71 238.75 238.76 238.79 287.5 288.50 288.51 288.59 288.61 288.69 288.8 453.0 789.2 Chronic lymphoid leukemia, in relapse Acute myeloid leukemia, without mention of having achieved remission Chronic myeloid leukemia, without mention of having achieved remission Polycythemia vera Essential thrombocythemia Myelodysplastic syndrome, unspecified Myelofibrosis with myeloid metaplasia Other lymphatic and hematopoietic tissues Thrombocytopenia unspecified Leukocytopenia, unspecified Lymphocytopenia Other decreased white blood cell count Lymphocytosis (symptomatic) Other elevated white blood cell count Other specified disease of white blood cells Budd-chiari syndrome Splenomegaly Multiple CPT codes exist for the various molecular tests for lymphoma. The appropriate code should be selected from the most current CPT manual. The following diagnosis codes meet coverage criteria as indications for molecular testing of lymphoma, so long as documentation of medical necessity for the specific test in question is present in the medical record, as noted elsewhere in this LCD: 200.40 200.41 200.42 200.43 200.44 200.45 200.46 200.47 200.48 200.70 200.71 200.72 200.73 200.74 200.75 200.76 200.77 200.78 202.00 202.01 202.02 Mantle cell lymphoma, unspecified site, extranodal and solid organ sites Mantle cell lymphoma, lymph nodes of head, face, and neck Mantle cell lymphoma, intrathoracic lymph nodes Mantle cell lymphoma, intra-abdominal lymph nodes Mantle cell lymphoma, lymph nodes of axilla and upper limb Mantle cell lymphoma, lymph nodes of inguinal region and lower limb Mantle cell lymphoma, intrapelvic lymph nodes Mantle cell lymphoma, spleen Mantle cell lymphoma, lymph nodes of multiple sites Large cell lymphoma, unspecified site, extranodal and solid organ sites Large cell lymphoma, lymph nodes of head, face, and neck Large cell lymphoma, intrathoracic lymph nodes Large cell lymphoma, intra-abdominal lymph nodes Large cell lymphoma, lymph nodes of axilla and upper limb Large cell lymphoma, lymph nodes of inguinal region and lower limb Large cell lymphoma, intrapelvic lymph nodes Large cell lymphoma, spleen Large cell lymphoma, lymph nodes of multiple sites Nodular lymphoma unspecified site Nodular lymphoma involving lymph nodes of head face and neck Nodular lymphoma involving intrathoracic lymph nodes 77 GENETIC TESTING (LCD) GENETIC TESTING Medicare B Medical Policy December 1, 2006; updated January 1, 2013 202.03 202.04 202.05 202.06 202.07 202.08 Nodular lymphoma involving intra-abdominal lymph nodes Nodular lymphoma involving lymph nodes of axilla and upper limb Nodular lymphoma involving lymph nodes of inguinal region and lower limb Nodular lymphoma involving intrapelvic lymph nodes Nodular lymphoma involving spleen Nodular lymphoma involving lymph nodes of multiple sites The following diagnosis codes when billed with CPT code 81403 meet coverage criteria as indications for testing for BCR/ABL fusion gene so long as documentation of medical necessity for the specific test in question is present in the medical record, as noted elsewhere in this LCD: 204.00 Acute lymphoid leukemia, without mention of having achieved remission 204.01 Lymphoid leukemia acute in remission 204.02 Acute lymphoid leukemia, in relapse 204.10 Chronic lymphoid leukemia, without mention of having achieved remission 204.11 Lymphoid leukemia chronic in remission 204.12 Chronic lymphoid leukemia, in relapse 204.20 Subacute lymphoid leukemia, without mention of having achieved remission 204.21 Lymphoid leukemia subacute in remission 204.22 Subacute lymphoid leukemia, in relapse 204.80 Other lymphoid leukemia, without mention of having achieved remission 204.81 Other lymphoid leukemia in remission 204.82 Other lymphoid leukemia, in relapse 204.90 Unspecified lymphoid leukemia, without mention of having achieved remission 204.91 Unspecified lymphoid leukemia in remission 204.92 Unspecified lymphoid leukemia, in relapse 205.00 Acute myeloid leukemia, without mention of having achieved remission 205.01 Myeloid leukemia acute in remission 205.02 Acute myeloid leukemia, in relapse 205.10 Chronic myeloid leukemia, without mention of having achieved remission 205.11 Myeloid leukemia chronic in remission 205.12 Chronic myeloid leukemia, in relapse 205.20 Subacute myeloid leukemia, without mention of having achieved remission 205.21 Myeloid leukemia subacute in remission 205.22 Subacute myeloid leukemia, in relapse 205.30 Myeloid sarcoma, without mention of having achieved remission 205.31 Myeloid sarcoma in remission 205.32 Myeloid sarcoma, in relapse 205.80 Other myeloid leukemia, without mention of having achieved remission 205.81 Other myeloid leukemia in remission 205.82 Other myeloid leukemia, in relapse 205.90 Unspecified myeloid leukemia, without mention of having achieved remission 205.91 Unspecified myeloid leukemia in remission 205.92 Unspecified myeloid leukemia, in relapse 206.00 Acute monocytic leukemia, without mention of having achieved remission 78 GENETIC TESTING (LCD) GENETIC TESTING Medicare B Medical Policy December 1, 2006; updated January 1, 2013 206.01 206.02 206.10 206.11 206.12 206.20 206.21 206.22 206.80 206.81 206.82 206.90 206.91 206.92 208.00 208.01 208.02 208.10 208.11 208.12 208.20 208.21 208.22 208.80 208.81 208.82 208.90 208.91 208.92 288.61 288.69 288.8 789.2 Monocytic leukemia acute in remission Acute monocytic leukemia, in relapse Chronic monocytic leukemia, without mention of having achieved remission Monocytic leukemia chronic in remission Chronic monocytic leukemia, in relapse Subacute monocytic leukemia, without mention of having achieved remission Monocytic leukemia subacute in remission Subacute monocytic leukemia, in relapse Other monocytic leukemia, without mention of having achieved remission Other monocytic leukemia in remission Other monocytic leukemia, in relapse Unspecified monocytic leukemia, without mention of having achieved remission Unspecified monocytic leukemia in remission Unspecified monocytic leukemia, in relapse Acute leukemia of unspecified cell type, without mention of having achieved remission Leukemia of unspecified cell type acute in remission Acute leukemia of unspecified cell type, in relapse Chronic leukemia of unspecified cell type, without mention of having achieved remission Leukemia of unspecified cell type chronic in remission Chronic leukemia of unspecified cell type, in relapse Subacute leukemia of unspecified cell type, without mention of having achieved remission Leukemia of unspecified cell type subacute in 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 remission Other leukemia of unspecified cell type, in relapse Unspecified leukemia, without mention of having achieved remission Unspecified leukemia in remission Unspecified leukemia, in relapse Lymphocytosis (symptomatic) Other elevated white blood cell count Other specified disease of white blood cells Splenomegaly The following diagnosis codes when billed with CPT code 81381 meet coverage criteria as indications for HLA-B*5701 testing prior to initiating abacavir therapy in patients with either Human Immunodeficiency Virus (HIV) disease or Asymptomatic Human Immunodeficiency virus (HIV) infection. 042 Human immunodeficiency virus (hiv) disease V08 Asymptomatic human immunodeficiency virus (hiv) infection status Reviewed: April 2013 79 GENETIC TESTING (LCD) 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 80 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 81 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 82 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 83 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 84 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 85 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 86 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 87 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 88 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 89 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 90 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 91 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 92 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 93 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 94 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 95 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 96 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 97 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 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 98 IRON STUDIES (NCD) IRON STUDIES; SERUM National Coverage Decision November 25, 2002 403.11 425.4 425.5 425.7 425.8 425.9 426.0-426.9 427.0-427.9 428.0-428.9 530.7 Hypertensive chronic kidney disease, benign with chronic kidney disease stage V or end stage renal disease 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 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 403.91 404.02 404.03 404.12 404.13 404.92 404.93 99 IRON STUDIES (NCD) IRON STUDIES; SERUM National Coverage Decision November 25, 2002 579.0-579.3 579.8-579.9 581.0-581.9 585.4-585.9 586 608.3 626.0-626.9 698.0-698.9 704.00-704.09 709.00-709.09 713.0 716.40-716.99 719.40-719.49 773.2 773.3 773.4 773.5 783.9 790.01-790.09 790.4 790.5 790.6 799.4 964.0 984.0-984.9 996.85 999.80 999.83 999.84 999.85 999.89 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 Intestinal malabsorption Other specified and unspecified intestinal malabsorption 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 627.0 627.1 648.20-648.24 100 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 101 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 102 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 103 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 176.3 197.4-197.5 197.8 199.0 204.00-204.92 205.00-208.92 209.00-209.03 209.10-209.17 209.40-209.43 209.50-209.57 209.70 209.71 209.72 209.73 209.74 209.75 209.79 211.0-211.9 228.04 230.2-230.9 235.2 235.5 104 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 105 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 106 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 107 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 197.7 198.0 198.1 200.00-200.88 202.00-202.98 209.20-209.29 209.70 209.71 209.72 209.73 209.74 209.75 209.79 223.0-223.9 238.4 238.5 238.6 238.71-238.79 239.4 239.5 239.9 246.3 249.40-249.41 250.40-250.43 263.0-263.9 108 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 109 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 - 425.9-425.9 427.0-427.9 428.0-428.9 429.0-429.4 429.79 430 431 432.0-432.9 433.00-433.91 434.00-434.91 435.0-435.9 436 437.0 437.1 437.6 440.0-440.9 441.0-441.9 443.0-443.9 444.01, 444.09, 444.1 - 444.9 447.1 447.2 447.6 448.0 448.9 451.0-451.9 452 453.0-453.9 455.2 455.5 Cardiac dysrhythmias Heart failure Ill-defined descriptions and complications of heart disease Other certain sequelae of myocardial infarction, not elsewhere classified Subarachnoid hemorrhage Intracerebral hemorrhage Other and unspecified intracranial hemorrhage Occlusion and stenosis of precerebral arteries Occlusion of cerebral arteries Transient cerebral ischemia Acute, but ill-defined cerebrovascular disease Cerebral atherosclerosis Other generalized ischemic cerebrovascular disease Nonpyogenic thrombosis of intracranial venous sinus Atherosclerosis Aortic aneurysm and dissection Other peripheral vascular disease Arterial embolism and thrombosis Stricture of artery Rupture of artery Arteritis, unspecified Hereditary hemorrhagic telangiectasia Other and unspecified capillary diseases Phlebitis and thrombophlebitis Portal vein thrombosis Other venous embolism and thrombosis Internal hemorrhoids with other complication External hemorrhoids with other complication 110 PT (NCD) PROTHROMBIN TIME National Coverage Decision November 25, 2002 455.8 456.0-456.1 456.8 459.0 459.10-459.19 459.2 459.81 459.89 511.81 511.89 514 530.7 530.82 530.86 530.87 531.00-535.71 555.0-555.9 556.0-556.9 557.0-557.9 562.02-562.03 562.10 562.11 562.12 562.13 568.81 569.3 571.0-571.9 572.2 572.4 572.8 573.1-573.9 576.0-576.9 577.0 578.0-578.9 579.0-579.9 581.0-581.9 583.9 584.5-584.9 585.4-585.9 586 593.81-593.89 596.7 596.81 596.82 596.83 596.89 599.70-599.72 607.82 608.83 611.89 620.7 Unspecified hemorrhoids with other complication Esophageal varices Varices of other sites Hemorrhage, unspecified Postphlebitis syndrome Compression of vein Venous (peripheral) insufficiency, unspecified Other, other specified disorders of circulatory system 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 111 PT (NCD) PROTHROMBIN TIME National Coverage Decision November 25, 2002 621.4 622.8 623.6 623.8 624.5 626.2-626.9 627.0 627.1 629.0 632 634.10-634.12 635.10-635.12 636.10-636.12 637.10-637.12 638.1 639.1 639.6 640.00-640.93 641.00-641.93 642.00-642.94 646.70-646.73 649.30-649.34 649.50-649.53 656.00-656.03 658.40-658.43 666.00-666.34 671.20-671.94 673.00-673.84 674.30-674.34 713.2 713.6 719.15 719.16 719.19 729.5 729.81 733.10 746.00-746.9 762.1 767.0,767.11 767.8 770.3 772.0-772.9 774.6 776.0-776.9 Hematometra Other specified noninflammatory disorders of cervix Vaginal hematoma Other specified noninflammatory disorders of the vagina Hematoma of vulva Abnormal bleeding from female genital tract Premenopausal menorrhagia Postmenopausal bleeding Hematocele female, not classified elsewhere Missed abortion Spontaneous abortion, complicated by excessive hemorrhage Legally induced abortion, complicated by delayed or excessive hemorrhage Illegally induced abortion, complicated by delayed or excessive hemorrhage Abortion unspecified, complicated by delayed or excessive hemorrhage Failed attempted abortion, complicated by delayed or excessive hemorrhage Delayed or excessive hemorrhage following abortion and ectopic and molar pregnancies Complications following abortion and ectopic and molar pregnancies with embolism Hemorrhage in early pregnancy Antepartum hemorrhage, abruptio placentae, and placenta previa Hypertension complicating pregnancy, childbirth, and the puerperium Liver disorders in pregnancy Coagulation defects complicating pregnancy, childbirth, or the puerperium, 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 112 PT (NCD) PROTHROMBIN TIME National Coverage Decision November 25, 2002 780.2 782.3 782.4 782.7 784.7 784.8 785.4 785.50 786.05 786.30 786.31 786.39 786.50 786.51 786.59 789.00-789.09 789.7 789.1 789.51 789.59 790.92 790.94 791.2 794.8 800.00-800.99 801.00-801.99 802.20-802.9 803.00-803.99 804.00-804.99 805.00-806.9 807.00-807.09 807.10-807.19 808.8-808.9 809.0-809.1 810.00-810.13 811.00-811.19 812.00-812.59 813.10-813.18 813.30-813.33 813.50-813.54 813.90-813.93 819.0-819.1 820.00-821.39 823.00-823.92 827.0-829.1 852.00-853.19 860.0-860.5 861.00-861.32 862.0-862.9 863.0-863.90 Syncope and collapse Edema Jaundice, unspecified, not of newborn Spontaneous ecchymosis Epistaxis Hemorrhage from throat Gangrene Shock without mention of trauma Shortness of breath Hemoptysis, 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 113 PT (NCD) PROTHROMBIN TIME National Coverage Decision November 25, 2002 863.91-863.95 & 863.99 864.00-864.19 865.00-865.19 866.00-866.13 867.0-867.9 868.00-868.19 869.0-869.1 900.00-900.9 901.0-901.9 902.0-902.9 903.00-903.9 904.0-904.9 920-924.9 925.1-929.9 958.2 959.9 964.0-964.9 980.0-980.9 981 982.0-982.8 987.0-987.9 989.0-989.9 995.20 Injury to Pancreas Injury to liver Injury to spleen Injury to kidney Injury to pelvic organs Injury to other intra-abdominal organs Internal injury to unspecified or ill defined organs Injury to blood vessels of head and neck Injury to blood vessels of the thorax Injury to blood vessels of the abdomen and pelvis Injury to blood vessels of upper extremity Injury to blood vessels of lower extremity and unspecified sites Contusion with intact skin surface Crushing injury Secondary and recurrent hemorrhage Injury, unspecified site Poisoning by agents primarily affecting blood constituents Toxic effect of alcohol Toxic effect of petroleum products Toxic effects of solvents other than petroleum-based Toxic effect of other gases, fumes or vapors Toxic effect of other substances chiefly non-medicinal as to source 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 114 PT (NCD) PROTHROMBIN TIME National Coverage Decision November 25, 2002 V42.6 V42.7 V42.81-V42.89 V43.21, V43.22 V43.3 V43.4 V58.2 V58.61 V58.83 Lung replaced by transplant Liver replaced by transplant Other specified organ or tissue replaced by transplant 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 115 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 277.1 277.30-277.39 285.1 286.0 286.1 286.2-286.3 286.4 286.52 286.53 286.59 286.6 116 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 117 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 118 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 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 119 PTT (NCD) PARTIAL THROMBOPLASTIN TIME National Coverage Decision November 25, 2002 790.92 800.00-800.99 801.00-801.99 802.20-802.9 803.00-803.99 804.00-804.99 805.00-806.9 807.00-807.09 807.10-807.19 808.8-808.9 809.0-809.1 810.00-810.13 811.00-811.19 812.00-812.59 813.10-813.18 813.30-813.33 813.50-813.54 813.90-813.93 819.0-819.1 820.00-821.39 823.00-823.92 827.0-829.1 852.00-853.19 860.0-860.5 861.00-861.32 862.0-862.9 863.0-863.99 864.00-864.19 865.00-865.19 866.00-866.13 867.0-867.9 868.00-868.19 869.0-869.1 900.00-900.9 901.0-901.9 902.0-902.9 903.00-903.9 904.0-904.9 920-924.9 925.1-929.9 958.2 959.9 964.2 964.5 964.7 980.0 989.5 995.20 995.21 995.24 Abnormal coagulation profile Fracture of vault of skull Fracture of base of skull Fracture of face bones Other fracture, skull Multiple fractures, skull Fracture, vertebral column Fractures of rib(s), closed 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 120 PTT (NCD) PARTIAL THROMBOPLASTIN TIME National Coverage Decision November 25, 2002 995.27 995.29 996.70-996.79 997.02 998.11 998.12 999.2 V12.3 V58.2 V58.61 V58.83 Other drug allergy 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 121 PTT (NCD) 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 122 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 123 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 124 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 125 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 126 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 639.5 646.60-646.64 670.00-670.04 670.10-670.14 670.20-670.24 670.30-670.34 670.80-670.84 672.00-672.04 724.5 771.81-771.83 780.02 780.60-780.65 780.66 780.79 780.93 780.94 780.96 780.97 780.99 785.0 785.50-785.59 788.0-788.99 789.00-789.09 789.60-789.69 789.7 790.7 791.0-791.9 127 URINE CULTURE (NCD) VITAMIN D ASSAY TESTING Medicare B Medical Policy November 14, 2011 CPT: 82306 CPT: 82652 Vitamin D; 25 Hydroxy, includes fraction(s), if performed Vitamin D; 1, 25 Hydroxy, includes fraction(s), if performed The following ICD-9 CM codes support the medical necessity of CPT code 82306 252.00 252.01 252.02 252.08 252.1 261 262 268.0 268.2 268.9* 275.3 275.40* 275.41 275.42 278.4 571.9 579.0 579.1 579.2 579.3 579.4 579.8 579.9 585.3 585.4 585.5 585.6 588.81 733.00 733.01 733.02 733.09 733.90 756.52 Hyperparathyroidism, unspecified Primary hyperparathyroidism Secondary hyperparathyroidism, non-renal Other hyperparathyroidism Hypoparathyroidism Nutritional marasmus Other severe protein-calorie malnutrition Rickets active Osteomalacia unspecified Unspecified vitamin D deficiency Disorders of phosphorus metabolism Unspecified disorder of calcium metabolism Hypocalcemia Hypercalcemia Hypervitaminosis D Unspecified chronic liver disease without alcohol Celiac disease Tropical sprue Blind loop syndrome Other and unspecified postsurgical nonabsorption Pancreatic steatorrhea Other specified intestinal malabsorption Unspecified intestinal malabsorption Chronic kidney disease, Stage III (moderate) Chronic kidney disease, Stage IV (severe) Chronic kidney disease, Stage V End Stage Renal Disease Secondary hyperparathyroidism, (of renal origin) Osteoporosis unspecified Senile osteoporosis Idiopathic osteoporosis Other osteoporosis Disorder of bone and cartilage unspecified Osteopetrosis 268.9* If more than one LCD-listed condition contributes to Vit. D deficiency in a given patient and/or is improved by Vit. D administration, coders should use: ICD-9-CM 268.9 UNSPECIFIED VITAMIN D DEFICIENCY. This code should not be used for any other indication. Use only for HYPERCALCINURIA 275.40* The following ICD-9-CM codes support the medical necessity of CPT code 82652 268.0 268.2* 275.40* 275.42* Rickets active Osteomalacia unspecified Unspecified disorder of calcium metabolism Hypercalcemia 128 Vitamin D Assay Testing (LCD) VITAMIN D ASSAY TESTING Medicare B Medical Policy November 14, 2011 592.0 592.1 592.9 Calculus of kidney Calculus of ureter Urinary calculus unspecified 268.2* 275.40* 275.42* Use only for tumor-induced osteomalacia Use only for unexplained hypercalcinuria Use only for unexplained hypocalcemia Reviewed: April 2013 129 Vitamin D Assay Testing (LCD) 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 130 CYTOGENETICS 285.29 Anemia of other chronic illnesses 285.9 Anemia, unspecified 783.41 Failure to thrive in childhood 758.7 Klinefelter's syndrome 203.00 Multiple myeloma, unspecified 202.80 Other malignant lymphomas, unspec site 289.89 Other specified diseases of blood 289.81 Primary hypercoagulable state 287.30 Primary thrombocytopenia, unspecified 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 April 2013 780.39 Seizures, not otherwise specified Common ICD-9 Codes 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 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 Screening for unspec cardiovascular V81.2 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 131 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 132 April 2013
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