Medicare National and Local Coverage Determination Policy – Texas
Medicare National and Local Coverage Determination Policy – Texas Policies in this MLCP Reference Guide apply to testing performed at a Quest Diagnostics facility and apply to Medicare National Coverage Determination Policy. This diagnosis code reference guide is provided as an aid to physicians and office staff in determining when an ABN (Advance Beneficiary Notice) is necessary. Diagnosis codes must be applicable to the patient’s symptoms or conditions and must be consistent with documentation in the patient’s medical record. Quest Diagnostics does not recommend any diagnosis codes and will only submit diagnosis information provided to us by the ordering physician or his/her designated staff. The CPT codes provided are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed. Please note this document has been updated with National Medicare changes effective 4/1/2012 • Click here for National MLCP Policies Tool Document contains information on National Medicare Limited Coverage Policies • • • • • • • • • • • • • • • • • • • • • • • Alpha-Fetoprotein Blood Counts Blood Glucose Testing Carcinoembryonic Antigen Collagen Crosslinks - Any Method Digoxin Therapeutic Drug Assay Fecal Occult Blood Gamma Glutamyl Transferase Glycated Hemoglobin - Glycated Protein Hepatitis Panel/Acute Hepatitis Panel Human Chorionic Gonadotropin Human Immunodeficiency Virus (HIV) Testing (Diagnosis) Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) Lipids Testing Partial Thromboplastin Time (PTT) Prostate Specific Antigen Prothrombin Time (PT) Serum Iron Studies Thyroid Testing Tumor Antigen by Immunoassay CA 15-3 CA 27.29 Tumor Antigen by Immunoassay CA 19-9 Tumor Antigen by Immunoassay CA-125 Urine Culture, Bacterial • Click policy below for Local MLCP Policy Tool Document contains the below Local Medicare Limited Coverage Policies for lab testing performed in Texas. • • • • • • • • • • • • • • • • • • • • Assays for Vitamins and Metabolic Function – Assay of Folic Acid Serum Assays for Vitamins and Metabolic Function – Assay of Carnitine Assays for Vitamins and Metabolic Function – Cell Function Assay with Stimulation Assays for Vitamins and Metabolic Function – C-Reactive Protein HS Assays for Vitamins and Metabolic Function – Fibrinogen, Antigen Assays for Vitamins and Metabolic Function – Assay of Homocysteine Assays for Vitamins and Metabolic Function – Assay Lipoprotein PLA2 Assays for Vitamins and Metabolic Function – Lymphocyte Transformation Assays for Vitamins and Metabolic Function – Vitamin B-6 Assays for Vitamins and Metabolic Function – Vitamin B-12 Assays for Vitamins and Metabolic Function – Vitamin D 1, 25-dihydroxy and Vitamin D, 25-hydroxy (Includes Fractions, If Performed) Biomarkers For Oncology Circulating Tumor Cell Assay Flow Cytometry Frequency of Laboratory Tests - Glucose Testing Frequency of Laboratory Tests – Lipids Frequency of Laboratory Tests – Thyroid Testing Molecular Diagnostics: Genitouriinary Infectious Disease Testing MyPRS Genetic Expression Profile Testing Qualitative Drug Screening QuestDiagnostics.com Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Last Updated: 03/25/13 Data Source: http://www.novitas-solutions.com Medicare Local Coverage Determination Policy - Texas L32614 Assays for Vitamins and Metabolic Function – Assay of Folic Acid Serum CPT Code: 82746 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Folate (82746) can be tested up to four times per year for malabsorption syndromes (579.9) or deficiency disorders (266.2, 281.1 and 281.2). ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Blood Folic Acid Serum test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 040.2 261 262 263 .0 263.2 Whipple's Disease Nutritional Marasmus Other Severe Protein-Calorie Malnutrition Malnutrition Of Moderate Degree Arrested Development Following Protein-Calorie Malnutrition 263.8 - 263.9 Other Protein-Calorie Malnutrition - Unspecified Protein-Calorie Malnutrition 266.2 Other B-Complex Deficiencies 270.4 Disturbances Of Sulphur-Bearing Amino-Acid Metabolism 281.0 - 281.3 Pernicious Anemia - Other Specified Megaloblastic Anemias Not Elsewhere Classified 281.9 Unspecified Deficiency Anemia 287.5 Thrombocytopenia Unspecified 290.0 Senile Dementia Uncomplicated 303.91 - 303.92 Other And Unspecified Alcohol Dependence Continuous Drinking Behavior - Other And Unspecified Alcohol Dependence Episodic Drinking Behavior 331.0 Alzheimer's Disease 333.99 Other Extrapyramidal Diseases And Abnormal Movement Disorders 356.4 356.9 529 .0 529.6 536 .0 555.0 - 555.2 555.9 579.0 - 579.4 579.8 - 579.9 780.93 780.99* 781.2 781.3 782 .0 V12.1 V45.11 V45.3 V58.11 V58.69 Idiopathic Progressive Polyneuropathy Unspecified Idiopathic Peripheral Neuropathy Glossitis Glossodynia Achlorhydria Regional Enteritis Of Small Intestine - Regional Enteritis Of Small Intestine With Large Intestine Regional Enteritis Of Unspecified Site Celiac Disease - Pancreatic Steatorrhea Other Specified Intestinal Malabsorption - Unspecified Intestinal Malabsorption Memory Loss Other General Symptoms *Note: Use code 780.99 to identify altered mental status Abnormality Of Gait Lack Of Coordination Disturbance Of Skin Sensation Personal History Of Nutritional Deficiency Renal Dialysis Status Postsurgical Intestinal Bypass Or Anastomosis Status Encounter For Antineoplastic Chemotherapy Long-Term (Current) Use Of Other Medications This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32614 Assays for Vitamins and Metabolic Function – Assay of Carnitine Data Source: http://www.novitas-solutions.com CPT Code: 82379 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Carnitine (82379) may be tested up to three times per year to account for baseline assay followed by evaluations at sixmonth increments (adapted from “Levocarnitine” NCD). ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Carnitine test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 277.81 - 277.84 Primary Carnitine Deficiency - Other Secondary Carnitine Deficiency 285.21 Anemia In Chronic Kidney Disease 458.21 Hypotension Of Hemodialysis This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32614 Assays for Vitamins and Metabolic Function – Cell Function Assay with Stimulation Data Source: http://www.novitas-solutions.com CPT Code: 86352 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Cell Function with Stimulation test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 279.10 - 279.13 996.81 - 996.88 V42.0 V42.1 V42.6 V42.7 V42.81 V42.83 V42.84 Immunodeficiency With Predominant T-Cell Defect Unspecified - Nezelof's Syndrome Complications Of Transplanted Kidney - Complications Of Transplanted Organ, Stem Cell Kidney Replaced By Transplant Heart Replaced By Transplant Lung Replaced By Transplant Liver Replaced By Transplant Bone Marrow Replaced By Transplant Pancreas Replaced By Transplant Organ Or Tissue Replaced By Transplant Intestines This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32614 Assays for Vitamins and Metabolic Function – C-Reactive Protein HS Data Source: http://www.novitas-solutions.com CPT Code: 86141 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Medicare will not cover more than two high-sensitivity C-reactive protein (86141) tests per year per beneficiary. This allows for baseline testing and six-month follow-up tests for statin therapeutic management. ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay C Reactive Protein test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 272.0 414.01 Pure Hypercholesterolemia Coronary atherosclerosis of native coronary artery This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 07/29/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32614 Assays for Vitamins and Metabolic Function – Fibrinogen Antigen Data Source: http://www.novitas-solutions.com CPT Code: 85385 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Fibrinogen (85385) may be tested up to four times per year for low platelet diagnoses (287.30–287.33, 287.41, 287.49, 287.5). ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Fibrinogen test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 286.3 Congenital Deficiency Of Other Clotting Factors 286.6 - 286.7 Defibrination Syndrome - Acquired Coagulation Factor Deficiency 287.30 - 287.33 Primary Thrombocytopenia,Unspecified - Congenital And Hereditary Thrombocytopenic Purpura 287.41 Posttransfusion Purpura 287.49 Other Secondary Thrombocytopenia 287.5 Thrombocytopenia Unspecified 790.92 Abnormal Coagulation Profile This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32614 Assays for Vitamins and Metabolic Function – Assay of Assay of Homocysteine CPT Code: 83090 Data Source: http://www.novitas-solutions.com LCD Description: LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Medicare will not cover more than one test per year, per beneficiary. ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Homocysteine test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 040.2 261 262 263 .0 263.2 Whipple's Disease Nutritional Marasmus Other Severe Protein-Calorie Malnutrition Malnutrition Of Moderate Degree Arrested Development Following Protein-Calorie Malnutrition 263.8 - 263.9 Other Protein-Calorie Malnutrition - Unspecified Protein-Calorie Malnutrition 266.2 Other B-Complex Deficiencies 270.4 Disturbances Of Sulphur-Bearing Amino-Acid Metabolism 281.0 - 281.3 Pernicious Anemia - Other Specified Megaloblastic Anemias Not Elsewhere Classified 281.9 Unspecified Deficiency Anemia 287.5 Thrombocytopenia Unspecified 290.0 Senile Dementia Uncomplicated 303.91 - 303.92 Other And Unspecified Alcohol Dependence Continuous Drinking Behavior - Other And Unspecified Alcohol Dependence Episodic Drinking Behavior 331.0 Alzheimer's Disease 333.99 Other Extrapyramidal Diseases And Abnormal Movement Disorders 356.4 356.9 529 .0 529.6 536 .0 555.0 - 555.2 555.9 579.0 - 579.4 579.8 - 579.9 780.93 780.99* 781.2 781.3 782 .0 V12.1 V45.11 V45.3 V58.11 V58.69 Idiopathic Progressive Polyneuropathy Unspecified Idiopathic Peripheral Neuropathy Glossitis Glossodynia Achlorhydria Regional Enteritis Of Small Intestine - Regional Enteritis Of Small Intestine With Large Intestine Regional Enteritis Of Unspecified Site Celiac Disease - Pancreatic Steatorrhea Other Specified Intestinal Malabsorption - Unspecified Intestinal Malabsorption Memory Loss Other General Symptoms *Note: Use code 780.99 to identify altered mental status Abnormality Of Gait Lack Of Coordination Disturbance Of Skin Sensation Personal History Of Nutritional Deficiency Renal Dialysis Status Postsurgical Intestinal Bypass Or Anastomosis Status Encounter For Antineoplastic Chemotherapy Long-Term (Current) Use Of Other Medications This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32614 Assays for Vitamins and Metabolic Function – Assay Lipoprotein PLA2 Data Source: http://www.novitas-solutions.com CPT Code: 83698 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: The same frequency edit (two tests per year per beneficiary) will be applied to Lipoprotein-associated phospholipase A2 (LpPLA2) used in the management of patients with coronary artery disease. ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Lipoprotein PLA2 test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 250.00 250.02 272.0 272.1 272.2 272.3 272.4 414.01 414.4 Diabetes Mellitus Without Mention Of Complication, Type Ii Or Unspecified Type, Not Stated As Uncontrolled Diabetes Mellitus Without Mention Of Complication, Type Ii Or Unspecified Type, Uncontrolled Pure Hypercholesterolemia Pure Hyperglyceridemia Mixed Hyperlipidemia Hyperchylomicronemia Other And Unspecified Hyperlipidemia Coronary Atherosclerosis Of Native Coronary Artery Coronary Atherosclerosis Due To Calcified Coronary Lesion This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 07/29/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32614 Assays for Vitamins and Metabolic Function – Lymphocyte Transformation Data Source: http://www.novitas-solutions.com CPT Code: 86353 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Lymphocyte Transformation test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 279.10 - 279.13 996.81 - 996.88 V42.0 V42.1 V42.6 V42.7 V42.81 V42.83 V42.84 Immunodeficiency With Predominant T-Cell Defect Unspecified - Nezelof's Syndrome Complications Of Transplanted Kidney - Complications Of Transplanted Organ, Stem Cell Kidney Replaced By Transplant Heart Replaced By Transplant Lung Replaced By Transplant Liver Replaced By Transplant Bone Marrow Replaced By Transplant Pancreas Replaced By Transplant Organ Or Tissue Replaced By Transplant Intestines This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32614 Assays for Vitamins and Metabolic Function – Assay of Vitamin B-6 CPT Code: 84207 Data Source: http://www.novitas-solutions.com LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Medicare will not cover more than one test per year, per beneficiary. ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Vitamin B-6 test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 266.1 285.0 333.99 356.9 529.0 Vitamin B6 Deficiency Sideroblastic Anemia Other Extrapyramidal Diseases And Abnormal Movement Disorders Unspecified Idiopathic Peripheral Neuropathy Glossitis This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32614 Assays for Vitamins and Metabolic Function – Vitamin B-12 CPT Code: 82607 Data Source: http://www.novitas-solutions.com LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Vitamin B-12 (82607) can be tested up to four times per year for malabsorption syndromes (579.9) or deficiency disorders (266.2, 281.1 and 281.2). Vitamin B-12 (82607) can only be tested more frequently than four times per year for postsurgical malabsorption (579.3). ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Vitamin B-12 test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 040.2 261 262 263 .0 263.2 Whipple's Disease Nutritional Marasmus Other Severe Protein-Calorie Malnutrition Malnutrition Of Moderate Degree Arrested Development Following Protein-Calorie Malnutrition 263.8 - 263.9 Other Protein-Calorie Malnutrition - Unspecified Protein-Calorie Malnutrition 266.2 Other B-Complex Deficiencies 270.4 Disturbances Of Sulphur-Bearing Amino-Acid Metabolism 281.0 - 281.3 Pernicious Anemia - Other Specified Megaloblastic Anemias Not Elsewhere Classified 281.9 Unspecified Deficiency Anemia 287.5 Thrombocytopenia Unspecified 290.0 Senile Dementia Uncomplicated 303.91 - 303.92 Other And Unspecified Alcohol Dependence Continuous Drinking Behavior - Other And Unspecified Alcohol Dependence Episodic Drinking Behavior 331.0 Alzheimer's Disease 333.99 Other Extrapyramidal Diseases And Abnormal Movement Disorders 356.4 356.9 529 .0 529.6 536 .0 555.0 - 555.2 555.9 579.0 - 579.4 579.8 - 579.9 780.93 780.99* 781.2 781.3 782 .0 V12.1 V45.11 V45.3 V58.11 V58.69 Idiopathic Progressive Polyneuropathy Unspecified Idiopathic Peripheral Neuropathy Glossitis Glossodynia Achlorhydria Regional Enteritis Of Small Intestine - Regional Enteritis Of Small Intestine With Large Intestine Regional Enteritis Of Unspecified Site Celiac Disease - Pancreatic Steatorrhea Other Specified Intestinal Malabsorption - Unspecified Intestinal Malabsorption Memory Loss Other General Symptoms *Note: Use code 780.99 to identify altered mental status Abnormality Of Gait Lack Of Coordination Disturbance Of Skin Sensation Personal History Of Nutritional Deficiency Renal Dialysis Status Postsurgical Intestinal Bypass Or Anastomosis Status Encounter For Antineoplastic Chemotherapy Long-Term (Current) Use Of Other Medications This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32614 Assays for Vitamins and Metabolic Function – Vitamin D 25-hydroxy and Vitamin D 1 25-dihydroxy (Includes Fractions if Performed) Data Source: http://www.novitas-solutions.com CPT Codes: 82306 and 82652 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: 25-OH Vitamin D-3 (82306) may be tested up to four times per year for Vitamin D deficiencies (268.0–268.9). ICD-9-CM Codes that Support Medical Necessity The Vitamin Assays Vitamin D, 25-hydroxy and Vitamin D1. 25-dihydroxy tests are determined to be medically necessary by Medicare only when they are ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 252.00 - 252.02 252.08 252.1 268.0 268.2 268.9 275.3 275.41 - 275.42 585.3 - 585.6 588.81 733.00 - 733.03 733.09 733.90 Hyperparathyroidism, Unspecified - Secondary Hyperparathyroidism, Non-Renal Other Hyperparathyroidism Hypoparathyroidism Rickets Active Osteomalacia Unspecified Unspecified Vitamin D Deficiency Disorders Of Phosphorus Metabolism Hypocalcemia - Hypercalcemia Chronic Kidney Disease, Stage III (Moderate) - End Stage Renal Disease Secondary Hyperparathyroidism (Of Renal Origin) Osteoporosis Unspecified - Disuse Osteoporosis Other Osteoporosis Disorder Of Bone And Cartilage Unspecified This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L33138 Biomarkers for Oncology (Page 1 of 3) Data Source: http://www.novitassolutions.com CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81261, 81262, 81263, 81264, 81270, 81275, 81310, 81315, 81316, 81340, 81341, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2013 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention.“ Utilization Guidelines: Unless otherwise specified, the biomarkers under limited coverage will be expected to only be performed once per lifetime. 81210 (BRAF GENE) 154.2 154.3 172.0 - 172.9 184.0 184.1 184.2 184.4 187.1 187.4 187.7 187.9 190 .0 Malignant Neoplasm Of Anal Canal Malignant Neoplasm Of Anus Unspecified Site Malignant Melanoma Of Skin Of Lip - Melanoma Of Skin Site Unspecified Neoplasm Of Vagina Malignant Neoplasm Of Labia Majora Malignant Neoplasm Of Labia Minora Malignant Neoplasm Of Vulva Unspecified Site Malignant Neoplasm Of Prepuce Malignant Neoplasm Of Penis Part Unspecified Malignant Neoplasm Of Scrotum Malignant Neoplasm Of Male Genital Organ Site Unspecified Malignant Neoplasm Of Eyeball Except Conjunctiva Cornea Retina And Choroid 190.2 Malignant Neoplasm Of Lacrimal Gland 190.3 Malignant Neoplasm Of Conjunctiva 190.5 Malignant Neoplasm Of Retina 190.6 Malignant Neoplasm Of Choroid 190.9 Malignant Neoplasm Of Eye Part Unspecified 193 Malignant Neoplasm Of Thyroid Gland 196.0 - 196.9 Secondary And Unspecified Malignant Neoplasm Of Lymph Nodes Of Head Face And Neck - Secondary And Unspecified Malignant Neoplasm Of Lymph Nodes Site Unspecified 197.0 - 197.8 Secondary Malignant Neoplasm Of Lung - Secondary Malignant Neoplasm Of Other Digestive Organs And Spleen 198.0 - 198.89 Secondary Malignant Neoplasm Of Kidney - Secondary Malignant Neoplasm Of Other Specified Sites 202.40 - 202.48 Leukemic Reticuloendotheliosis Unspecified Site - Leukemic Reticuloendotheliosis Involving Lymph Nodes Of Multiple Sites This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 07/26/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L33138 Biomarkers for Oncology (Page 2 of 3) Data Source: http://www.novitas-solutions.com CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81261, 81262, 81263, 81264, 81270, 81275, 81310, 81315, 81316, 81340, 81341, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2013 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention.“ Utilization Guidelines: Unless otherwise specified, the biomarkers under limited coverage will be expected to only be performed once per lifetime. 81235 (EGFR GENE COM VARIANTS) 162.0 - 162.9 163.0 - 163.9 Malignant Neoplasm Of Trachea - Malignant Neoplasm Of Bronchus And Lung Unspecified Malignant Neoplasm Of Parietal Pleura - Malignant Neoplasm Of Pleura Unspecified 81270 (JAK2 GENE) 238.4 238.71 238.75 238.76 238.79 238.9 288.61 288.8 289.0 - 289.9 Polycythemia Vera Essential Thrombocythemia Myelodysplastic Syndrome, Unspecified Myelofibrosis With Myeloid Metaplasia Other Lymphatic And Hematopoietic Tissues Neoplasm Of Uncertain Behavior Site Unspecified Lymphocytosis (Symptomatic) Other Specified Disease Of White Blood Cells Polycythemia Secondary - Unspecified Diseases Of Blood And Blood-Forming Organs 81275 (KRAS GENE) 153.0 - 153.9 154.0 154.1 154.8 Malignant Neoplasm Of Hepatic Flexure - Malignant Neoplasm Of Colon Unspecified Site Malignant Neoplasm Of Rectosigmoid Junction Malignant Neoplasm Of Rectum Malignant Neoplasm Of Other Sites Of Rectum Rectosigmoid Junction And Anus This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 07/26/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L33138 Biomarkers for Oncology (Page 3 of 3) Data Source: http://www.novitas-solutions.com CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81261, 81262, 81263, 81264, 81270, 81275, 81310, 81315, 81316, 81340, 81341, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2013 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention.“ Utilization Guidelines: Unless otherwise specified, the biomarkers under limited coverage will be expected to only be performed once per lifetime. …Until the accrual of sufficient evidence has been completed, claims for oncology biomarker testing will be evaluated on an individual consideration basis: 81206 81207 81208 81245 81261 81262 81263 81264 81315 81316 81340 Bcr/Abl1 Gene Major Bp Bcr/Abl1 Gene Minor Bp Bcr/Abl1 Gene Other Bp Flt3 Gene Igh Gene Rearrange Amp Meth Igh Gene Rearrang Dir Probe Igh Vari Regional Mutation Igk Rearrangeabn Clonal Pop81310 Npm1 Gene Pml/Raralpha Com Breakpoints Pml/Raralpha 1 Breakpoint Trb@ Gene Rearrange Amplify 81341 81342 81350 81400 81401 81402 81403 81404 81405 81406 81407 81408 Trb@ Gene Rearrange Dirprobe Trg Gene Rearrangement Anal Ugt1A1 Gene Mopath Procedure Level 1 Mopath Procedure Level 2 Mopath Procedure Level 3 Mopath Procedure Level 4 Mopath Procedure Level 5 Mopath Procedure Level 6 Mopath Procedure Level 7 Mopath Procedure Level 8 Mopath Procedure Level 9 This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 07/26/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32694 Circulating Tumor Cell Assay CPT Codes: 86152, 86153 Non-Coverage Policy Data Source: http://www.novitas-solutions.com LCD Description: Circulating tumor cells (CTCs) are noted to be extremely rare in individuals without malignancy. However, CTCs have been noted in a wide variety of metastatic carcinomas. Also, studies have suggested the presence of circulating tumor cells in patients with metastatic carcinoma is associated with short survival. Some have suggested that quantifying these tumor cells might be useful in providing an immediate assessment of response to chemotherapy rather than relying on imaging studies. In patients with non-metastatic breast cancer, circulating tumor cells have been investigated for use in predicting a need for adjuvant chemotherapy. This is a noncoverage policy for these assays including the CellSearch and PCR (RT-PCR) assays. Current techniques to quantify CTCs include an immunomagnetic/fluorescent assay and reverse transcription PCR for the detection genetic products such as cytokeratin, MUC-1, CEA, EpCAM and mammoglobulin. This assay involves the automated immunomagnetic selection of CTCs based on an anti-EpCAM antibody cell capture. Digital fluorescent images are interpreted by a technician and reported as a numerical result where more than 5 cells per 7.5 ml of whole blood predicts worse outcomes in patients with known recurrent breast and prostate cancer, and more than 3 cells predictive of shorter progression free survival and overall survival in metastatic colorectal cancer. ICD-9-CM Codes that Support Medical Necessity The Circulating Tumor Cell Assay test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. At this time, there are no definitive studies that show the clinical use for detection of circulating tumor cells. These assays are considered investigational and not a covered Medicare benefit. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 1 of 19) Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA Data Source: www.cms.com CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 042 Human Immunodeficiency Virus (Hiv) Disease 079.51 - 079.53 Human T-Cell Lymphotrophic Virus Type I [Htlv-I] – Human Immunodeficiency Virus Type 2 [Hiv-2] 099.3 Reiter's Disease 150.0 - 150.5 Malignant Neoplasm Of Cervical Esophagus - Malignant Neoplasm Of Lower Third Of Esophagus 150.8 Malignant Neoplasm Of Other Specified Part Of Esophagus 150.9 Malignant Neoplasm Of Esophagus Unspecified Site 151.0 - 151.6 Malignant Neoplasm Of Cardia - Malignant Neoplasm Of Greater Curvature Of Stomach Unspecified 151.8 Malignant Neoplasm Of Other Specified Sites Of Stomach 151.9 Malignant Neoplasm Of Stomach Unspecified Site 152.0 Malignant Neoplasm Of Duodenum 152.1 Malignant Neoplasm Of Jejunum 152.2 Malignant Neoplasm Of Ileum 152.8 152.9 153.0 - 153.9 154.0 154.1 154.2 154.3 154.8 155.0 155.2 156.0 156.1 Malignant Neoplasm Of Other Specified Sites Of Small Intestine Malignant Neoplasm Of Small Intestine Unspecified Site Malignant Neoplasm Of Hepatic Flexure - Malignant Neoplasm Of Colon Unspecified Site Malignant Neoplasm Of Rectosigmoid Junction. Malignant Neoplasm Of Rectum Malignant Neoplasm Of Anal Canal Malignant Neoplasm Of Anus Unspecified Site Malignant Neoplasm Of Other Sites Of Rectum Rectosigmoid Junction And Anus Malignant Neoplasm Of Liver Primary Malignant Neoplasm Of Liver Not Specified As Primary Or Secondary Malignant Neoplasm Of Gallbladder Malignant Neoplasm Of Extrahepatic Bile Ducts This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 2 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 156.2 157.0 157.1 157.2 157.8 157.9 158.0 158.8 158.9 159.0 159.1 159.8 159.9 Malignant Neoplasm Of Ampulla Of Vater Malignant Neoplasm Of Head Of Pancreas Malignant Neoplasm Of Body Of Pancreas Malignant Neoplasm Of Tail Of Pancreas Malignant Neoplasm Of Other Specified Sites Of Pancreas Malignant Neoplasm Of Pancreas Part Unspecified Malignant Neoplasm Of Retroperitoneum Malignant Neoplasm Of Specified Parts Of Peritoneum Malignant Neoplasm Of Peritoneum Unspecified Malignant Neoplasm Of Intestinal Tract Part Unspecified Malignant Neoplasm Of Spleen Not Elsewhere Classified Malignant Neoplasm Of Other Sites Of Digestive System And Intra-Abdominal Organs Malignant Neoplasm Of Ill-Defined Sites Within The Digestive Organs And Peritoneum 160.0 160.1 160.2 160.3 160.4 160.5 160.8 160.9 161.0 161.1 161.2 161.3 161.8 161.9 162.0 Malignant Neoplasm Of Nasal Cavities Malignant Neoplasm Of Auditory Tube Middle Ear And Mastoid Air Cells Malignant Neoplasm Of Maxillary Sinus Malignant Neoplasm Of Ethmoidal Sinus Malignant Neoplasm Of Frontal Sinus Malignant Neoplasm Of Sphenoidal Sinus Malignant Neoplasm Of Other Accessory Sinuses Malignant Neoplasm Of Accessory Sinus Unspecified Malignant Neoplasm Of Glottis Malignant Neoplasm Of Supraglottis Malignant Neoplasm Of Subglottis Malignant Neoplasm Of Laryngeal Cartilages Malignant Neoplasm Of Other Specified Sites Of Larynx Malignant Neoplasm Of Larynx Unspecified Malignant Neoplasm Of Trachea This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 3 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 162.2 162.3 162.4 162.5 162.8 162.9 163.0 163.1 163.8 163.9 164.0 164.2 164.3 164.8 164.9 Malignant Neoplasm Of Main Bronchus Malignant Neoplasm Of Upper Lobe Bronchus Or Lung Malignant Neoplasm Of Middle Lobe Bronchus Or Lung Malignant Neoplasm Of Lower Lobe Bronchus Or Lung Malignant Neoplasm Of Other Parts Of Bronchus Or Lung Malignant Neoplasm Of Bronchus And Lung Unspecified Malignant Neoplasm Of Parietal Pleura Malignant Neoplasm Of Visceral Pleura Malignant Neoplasm Of Other Specified Sites Of Pleura Malignant Neoplasm Of Pleura Unspecified Malignant Neoplasm Of Thymus Malignant Neoplasm Of Anterior Mediastinum Malignant Neoplasm Of Posterior Mediastinum Malignant Neoplasm Of Other Parts Of Mediastinum Malignant Neoplasm Of Mediastinum Part Unspecified 165.0 165.8 165.9 170.0 170.2 170.3 170.4 170.5 170.6 Malignant Neoplasm Of Upper Respiratory Tract Part Unspecified Malignant Neoplasm Of Other Sites Within The Respiratory System And Intrathoracic Organs Malignant Neoplasm Of Ill-Defined Sites Within The Respiratory System Malignant Neoplasm Of Bones Of Skull And Face Except Mandible Malignant Neoplasm Of Vertebral Column Excluding Sacrum And Coccyx Malignant Neoplasm Of Ribs Sternum And Clavicle Malignant Neoplasm Of Scapula And Long Bones Of Upper Limb Malignant Neoplasm Of Short Bones Of Upper Limb Malignant Neoplasm Of Pelvic Bones Sacrum And Coccyx This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 4 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 170.7 170.8 170.9 171.0 171.2 171.3 171.4 171.5 171.6 Malignant Neoplasm Of Long Bones Of Lower Limb Malignant Neoplasm Of Short Bones Of Lower Limb Malignant Neoplasm Of Bone And Articular Cartilage Site Unspecified Malignant Neoplasm Of Connective And Other Soft Tissue Of Head Face And Neck Malignant Neoplasm Of Connective And Other Soft Tissue Of Upper Limb Including Shoulder Malignant Neoplasm Of Connective And Other Soft Tissue Of Lower Limb Including Hip Malignant Neoplasm Of Connective And Other Soft Tissue Of Thorax Malignant Neoplasm Of Connective And Other Soft Tissue Of Abdomen Malignant Neoplasm Of Connective And Other Soft Tissue Of Pelvis 171.7 171.8 171.9 173.00 173.01 173.02 173.09 173.10 173.11 173.12 173.19 Malignant Neoplasm Of Connective And Other Soft Tissue Of Trunk Unspecified Malignant Neoplasm Of Other Specified Sites Of Connective And Other Soft Tissue Malignant Neoplasm Of Connective And Other Soft Tissue Site Unspecified Unspecified Malignant Neoplasm Of Skin Of Lip Basal Cell Carcinoma Of Skin Of Lip Squamous Cell Carcinoma Of Skin Of Lip Other Specified Malignant Neoplasm Of Skin Of Lip Unspecified Malignant Neoplasm Of Eyelid, Including Canthus Basal Cell Carcinoma Of Eyelid, Including Canthus Squamous Cell Carcinoma Of Eyelid, Including Canthus Other Specified Malignant Neoplasm Of Eyelid, Including Canthus This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 5 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 173.20 173.21 173.22 173.29 173.30 173.31 173.32 173.39 Unspecified Malignant Neoplasm Of Skin Of Ear And External Auditory Canal Basal Cell Carcinoma Of Skin Of Ear And External Auditory Canal Squamous Cell Carcinoma Of Skin Of Ear And External Auditory Canal Other Specified Malignant Neoplasm Of Skin Of Ear And External Auditory Canal Unspecified Malignant Neoplasm Of Skin Of Other And Unspecified Parts Of Face Basal Cell Carcinoma Of Skin Of Other And Unspecified Parts Of Face Squamous Cell Carcinoma Of Skin Of Other And Unspecified Parts Of Face Other Specified Malignant Neoplasm Of Skin Of Other And Unspecified Parts Of Face 173.40 173.41 173.42 173.49 173.50 173.51 173.52 173.59 173.60 Unspecified Malignant Neoplasm Of Scalp And Skin Of Neck Basal Cell Carcinoma Of Scalp And Skin Of Neck Squamous Cell Carcinoma Of Scalp And Skin Of Neck Other Specified Malignant Neoplasm Of Scalp And Skin Of Neck Unspecified Malignant Neoplasm Of Skin Of Trunk, Except Scrotum Basal Cell Carcinoma Of Skin Of Trunk, Except Scrotum Squamous Cell Carcinoma Of Skin Of Trunk, Except Scrotum Other Specified Malignant Neoplasm Of Skin Of Trunk, Except Scrotum Unspecified Malignant Neoplasm Of Skin Of Upper Limb, Including Shoulder This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 6 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 173.61 173.62 173.69 173.70 173.71 173.72 173.79 173.80 Basal Cell Carcinoma Of Skin Of Upper Limb, Including Shoulder Squamous Cell Carcinoma Of Skin Of Upper Limb, Including Shoulder Other Specified Malignant Neoplasm Of Skin Of Upper Limb, Including Shoulder Unspecified Malignant Neoplasm Of Skin Of Lower Limb, Including Hip Basal Cell Carcinoma Of Skin Of Lower Limb, Including Hip Squamous Cell Carcinoma Of Skin Of Lower Limb, Including Hip Other Specified Malignant Neoplasm Of Skin Of Lower Limb, Including Hip Unspecified Malignant Neoplasm Of Other Specified Sites Of Skin 173.81 173.82 173.89 173.90 173.91 173.92 173.99 174.0 - 174.6 174.8 Basal Cell Carcinoma Of Other Specified Sites Of Skin Squamous Cell Carcinoma Of Other Specified Sites Of Skin Other Specified Malignant Neoplasm Of Other Specified Sites Of Skin Unspecified Malignant Neoplasm Of Skin, Site Unspecified Basal Cell Carcinoma Of Skin, Site Unspecified Squamous Cell Carcinoma Of Skin, Site Unspecified Other Specified Malignant Neoplasm Of Skin, Site Unspecified Malignant Neoplasm Of Nipple And Areola Of Female Breast - Malignant Neoplasm Of Axillary Tail Of Female Breast Malignant Neoplasm Of Other Specified Sites Of Female Breast This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 7 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 174.9 175.0 175.9 176.0 176.1 176.2 176.3 176.4 176.5 176.8 176.9 179 180.0 180.1 180.8 Malignant Neoplasm Of Breast (Female) Unspecified Site Malignant Neoplasm Of Nipple And Areola Of Male Breat Malignant Neoplasm Of Other And Unspecified Sites Of Male Breast Kaposi's Sarcoma Skin Kaposi's Sarcoma Soft Tissue Kaposi's Sarcoma Palate Kaposi's Sarcoma Gastrointestinal Sites Kaposi's Sarcoma Lung Kaposi's Sarcoma Lymph Nodes Kaposi's Sarcoma Other Specified Sites Kaposi's Sarcoma Unspecified Site Malignant Neoplasm Of Uterus-Part Uns Malignant Neoplasm Of Endocervix Malignant Neoplasm Of Exocervix Malignant Neoplasm Of Other Specified Sites Of Cervix 180.9 181 182.0 182.1 182.8 183.0 183.8 184.0 184.1 184.2 184.3 184.4 184.8 Malignant Neoplasm Of Cervix Uteri Unspecified Site Malignant Neoplasm Of Placenta Malignant Neoplasm Of Corpus Uteri Except Isthmus Malignant Neoplasm Of Isthmus Malignant Neoplasm Of Other Specified Sites Of Body Of Uterus Malignant Neoplasm Of Ovary Malignant Neoplasm Of Other Specified Sites Of Uterine Adnexa Malignant Neoplasm Of Vagina Malignant Neoplasm Of Labia Majora Malignant Neoplasm Of Labia Minora Malignant Neoplasm Of Clitoris Malignant Neoplasm Of Vulva Unspecified Site Malignant Neoplasm Of Other Specified Sites Of Female Genital Organs This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 8 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 184.9 185 186.0 186.9 187.1 187.2 187.3 187.4 187.5 187.6 187.7 187.8 187.9 Malignant Neoplasm Of Female Genital Organ Site Unspecified Malignant Neoplasm Of Prostate Malignant Neoplasm Of Undescended Testis Malignant Neoplasm Of Other And Unspecified Testis Malignant Neoplasm Of Prepuce Malignant Neoplasm Of Glans Penis Malignant Neoplasm Of Body Of Penis Malignant Neoplasm Of Penis Part Unspecified Malignant Neoplasm Of Epididymis Malignant Neoplasm Of Spermatic Cord Malignant Neoplasm Of Scrotum Malignant Neoplasm Of Other Specified Sites Of Male Genital Organs Malignant Neoplasm Of Male Genital Organ Site Unspecified 188.0 - 188.9 189.0 189.1 189.2 189.3 189.4 189.8 189.9 190.0 - 190.9 191.0 - 191.9 Malignant Neoplasm Of Trigone Of Urinary Bladder – Malignant Neoplasm Of Bladder Part Unspecified Malignant Neoplasm Of Kidney Except Pelvis Malignant Neoplasm Of Renal Pelvis Malignant Neoplasm Of Ureter Malignant Neoplasm Of Urethra Malignant Neoplasm Of Paraurethral Glands Malignant Neoplasm Of Other Specified Sites Of Urinary Organs Malignant Neoplasm Of Urinary Organ Site Unspecified Malignant Neoplasm Of Eyeball Except Conjunctiva Cornea Retina And Choroid - Malignant Neoplasm Of Eye Part Unspecified Malignant Neoplasm Of Cerebrum Except Lobes And Ventricles - Malignant Neoplasm Of Brain Unspecified Site This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 9 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 192.0 192.1 192.2 192.3 192.8 192.9 193 194.0 194.1 194.3 194.4 194.5 194.6 Malignant Neoplasm Of Cranial Nerves Malignant Neoplasm Of Cerebral Meninges Malignant Neoplasm Of Spinal Cord Malignant Neoplasm Of Spinal Meninges Malignant Neoplasm Of Other Specified Sites Of Nervous System Malignant Neoplasm Of Nervous System Part Unspecified Malignant Neoplasm Of Thyroid Gland Malignant Neoplasm Of Adrenal Gland Malignant Neoplasm Of Parathyroid Gland Malignant Neoplasm Of Pituitary Gland And Craniopharyngeal Duct Malignant Neoplasm Of Pineal Gland Malignant Neoplasm Of Carotid Body Malignant Neoplasm Of Aortic Body And Other Paraganglia 194.8 194.9 195.0 - 195.5 195.8 196.0 196.1 196.2 196.3 Malignant Neoplasm Of Other Endocrine Glands And Related Structures Malignant Neoplasm Of Endocrine Gland Site Unspecified Malignant Neoplasm Of Head Face And Neck - Malignant Neoplasm Of Lower Limb Malignant Neoplasm Of Other Specified Sites Secondary And Unspecified Malignant Neoplasm Of Of Lymph Nodes of Head, Face and Neck Secondary And Unspecified Malignant Neoplasm Of Intrathoracic Lymph Nodes Secondary And Unspecified Malignant Neoplasm Of Intra-Abdominal Lymph Nodes Secondary And Unspecified Malignant Neoplasm Of Lymph Nodes Of Axilla And Upper Limb This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 10 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 196.5 196.6 196.8 196.9 197.0 197.1 197.2 197.3 197.4 Secondary And Unspecified Malignant Neoplasm Of Lymph Nodes Of Inguinal Region And Lower Limb Secondary And Unspecified Malignant Neoplasm Of Intrapelvic Lymph Nodes Secondary And Unspecified Malignant Neoplasm Of Lymph Nodes Of Multiple Sites Secondary And Unspecified Malignant Neoplasm Of Lymph Nodes Site Unspecified Secondary Malignant Neoplasm Of Lung Secondary Malignant Neoplasm Of Mediastinum Secondary Malignant Neoplasm Of Pleura Secondary Malignant Neoplasm Of Other Respiratory Organs Secondary Malignant Neoplasm Of Small Intestine Including Duodenum 197.5 Secondary Malignant Neoplasm Of Large Intestine And Rectum 197.6 Secondary Malignant Neoplasm Of Retroperitoneum And Peritoneum 198.0 - 198.7 Secondary Malignant Neoplasm Of Kidney - Secondary Malignant Neoplasm Of Adrenal Gland 198.81 Secondary Malignant Neoplasm Of Breast 198.82 Secondary Malignant Neoplasm Of Genital Organs 198.89 Secondary Malignant Neoplasm Of Other Specified Sites 199.0 Disseminated Malignant Neoplasm 199.1 Other Malignant Neoplasm Of Unspecified Site 200.00 - 200.08 Reticulosarcoma Unspecified Site - Reticulosarcoma Involving Lymph Nodes Of Multiple Sites 200.10 - 200.18 Lymphosarcoma Unspecified Site - Lymphosarcoma Involving Lymph Nodes Of Multiple Sites This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 11 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 200.20 - 200.28 Burkitt's Tumor Or Lymphoma Unspecified Site – Burkitt's Tumor Or Lymphoma Involving Lymph Nodes Of Multiple Sites 200.30 - 200.38 Marginal Zone Lymphoma, Unspecified Site, Extranodal And Solid Organ Sites - Marginal Zone Lymphoma, Lymph Nodes Of Multiple Sites 200.40 - 200.48 Mantle Cell Lymphoma, Unspecified Site, Extranodal And Solid Organ Sites - Mantle Cell Lymphoma, Lymph Nodes Of Multiple Sites 200.50 - 200.58 Primary Central Nervous System Lymphoma, Unspecified Site, Extranodal And Solid Organ Sites - Primary Central Nervous System Lymphoma, Lymph Nodes Of Multiple Sites 200.60 - 200.68 Anaplastic Large Cell Lymphoma, Unspecified Site, Extranodal And Solid Organ Sites - Anaplastic Large Cell Lymphoma, Lymph Nodes Of Multiple Sites 200.70 - 200.78 Large Cell Lymphoma, Unspecified Site, Extranodal And Solid Organ Sites - Large Cell Lymphoma, Lymph Nodes Of Multiple Sites 200.80 - 200.88 Other Named Variants Of Lymphosarcoma And Reticulosarcoma Unspecified Site - Other Named Variants Of Lymphosarcoma And Reticulosarcoma Involving Lymph Nodes Of Multiple Sites 201.00 - 201.08 Hodgkin's Paragranuloma Unspecified Site - Hodgkin's Paragranuloma Involving Lymph Nodes Of Multiple Sites 201.10 - 201.18 Hodgkin's Granuloma Unspecified Site - Hodgkin's Granuloma Involving Lymph Nodes Of Multiple Sites 201.20 - 201.28 Hodgkin's Sarcoma Unspecified Site - Hodgkin's Sarcoma Involving Lymph Nodes Of Multiple Sites 201.40 - 201.48 Hodgkin's Disease Lymphocytic--Histiocytic Predominance Unspecified Site - Hodgkin's Disease Lymphocytic-Histiocytic Predominance Involving Lymph Nodes Of Multiple Sites This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 12 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 201.50 - 201.58 Hodgkin's Disease Nodular Sclerosis Unspecified Site – Hodgkin's Disease Nodular Sclerosis Involving Lymph Nodes Of Multiple Sites 201.60 - 201.68 Hodgkin's Disease Mixed Cellularity Unspecified Site – Hodgkin's Disease Mixed Cellularity Involving Lymph Nodes Of Multiple Sites 201.70 - 201.78 Hodgkin's Disease Lymphocytic Depletion Unspecified Site - Hodgkin's Disease Lymphocytic Depletion Involving Lymph Nodes Of Multiple Sites 201.90 - 201.98 Hodgkin's Disease Unspecified Type Unspecified Site – Hodgkin's Disease Unspecified Type Involving Lymph Nodes Of Multiple Sites 202.00 - 202.08 Nodular Lymphoma Unspecified Site - Nodular Lymphoma Involving Lymph Nodes Of Multiple Sites 202.10 - 202.18 Mycosis Fungoides Unspecified Site - Mycosis Fungoides Involving Lymph Nodes Of Multiple Sites 202.20 - 202.28 202.30 - 202.38 202.40 - 202.48 202.50 - 202.58 202.60 - 202.68 202.70 - 202.78 Sezary's Disease Unspecified Site - Sezary's Disease Involving Lymph Nodes Of Multiple Sites Malignant Histiocytosis Unspecified Site - Malignant Histiocytosis Involving Lymph Nodes Of Multiple Sites Leukemic Reticuloendotheliosis Unspecified Site – Leukemic Reticuloendotheliosis Involving Lymph Nodes Of Multiple Sites Letterer-Siwe Disease Unspecified Site - Letterer-Siwe Disease Involving Lymph Nodes Of Multiple Sites Malignant Mast Cell Tumors Unspecified Site – Malignant Mast Cell Tumors Involving Lymph Nodes Of Multiple Sites Peripheral T Cell Lymphoma, Unspecified Site, Extranodal And Solid Organ Sites - Peripheral T Cell Lymphoma, Lymph Nodes Of Multiple Sites This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 13 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 202.80 - 202.88 202.90 - 202.98 203.00 - 203.02 203.10 - 203.12 203.80 - 203.82 Other Malignant Lymphomas Unspecified Site - Other Malignant Lymphomas Involving Lymph Nodes Of Multiple Sites Other And Unspecified Malignant Neoplasms Of Lymphoid And Histiocytic Tissue Unspecified Site – Other And Unspecified Malignant Neoplasms Of Lymphoid And Histiocytic Tissue Involving Lymph Nodes Of Multiple Sites Multiple Myeloma, Without Mention Of Having Achieved Remission - Multiple Myeloma, In Relapse Plasma Cell Leukemia, Without Mention Of Having Achieved Remission - Plasma Cell Leukemia, In Relapse Other Immunoproliferative Neoplasms, Without Mention Of Having Achieved Remission - Other Immunoproliferative Neoplasms, In Relapse 204.00 - 204.02 Acute Lymphoid Leukemia, Without Mention Of Having Achieved Remission - Acute Lymphoid Leukemia, In Relapse 204.10 - 204.12 Chronic Lymphoid Leukemia, Without Mention Of Having Achieved Remission - Chronic Lymphoid Leukemia, In Relapse 204.20 - 204.22 Subacute Lymphoid Leukemia, Without Mention Of Having Achieved Remission - Subacute Lymphoid Leukemia, In Relapse 204.80 - 204.82 Other Lymphoid Leukemia, Without Mention Of Having Achieved Remission - Other Lymphoid Leukemia, In Relapse 204.90 - 204.92 Unspecified Lymphoid Leukemia, Without Mention Of Having Achieved Remission - Unspecified Lymphoid Leukemia, In Relapse This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 14 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 205.00 - 205.02 Acute Myeloid Leukemia, Without Mention Of Having Achieved Remission - Acute Myeloid Leukemia, In Relapse 205.10 - 205.12 Chronic Myeloid Leukemia, Without Mention Of Having Achieved Remission - Chronic Myeloid Leukemia, In Relapse 205.20 - 205.22 Subacute Myeloid Leukemia, Without Mention Of Having Achieved Remission - Subacute Myeloid Leukemia, In Relapse 205.30 - 205.32 Myeloid Sarcoma, Without Mention Of Having Achieved Remission - Myeloid Sarcoma, In Relapse 205.80 - 205.82 Other Myeloid Leukemia, Without Mention Of Having Achieved Remission - Other Myeloid Leukemia, In Relapse 205.90 - 205.92 Unspecified Myeloid Leukemia, Without Mention Of Having Achieved Remission - Unspecified Myeloid Leukemia, In Relapse 206.00 - 206.02 Acute Monocytic Leukemia, Without Mention Of Having Achieved Remission - Acute Monocytic Leukemia, In Relapse 206.10 - 206.12 Chronic Monocytic Leukemia, Without Mention Of Having Achieved Remission - Chronic Monocytic Leukemia, In Relapse 206.20 - 206.22 Subacute Monocytic Leukemia, Without Mention Of Having Achieved Remission - Subacute Monocytic Leukemia, In Relapse 206.80 - 206.82 Other Monocytic Leukemia, Without Mention Of Having Achieved Remission - Other Monocytic Leukemia, In Relapse 206.90 - 206.92 Unspecified Monocytic Leukemia, Without Mention Of Having Achieved Remission - Unspecified Monocytic Leukemia, In Relapse 207.00 - 207.02 Acute Erythremia And Erythroleukemia, Without Mention Of Having Achieved Remission - Acute Erythremia And Erythroleukemia, In Relapse This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 15 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 207.10 - 207.12 Chronic Erythremia, Without Mention Of Having Achieved Remission - Chronic Erythremia, In Relapse 207.20 - 207.22 Megakaryocytic Leukemia, Without Mention Of Having Achieved Remission - Megakaryocytic Leukemia, In Relapse 207.80 - 207.82 Other Specified Leukemia, Without Mention Of Having Achieved Remission - Other Specified Leukemia, In Relapse 208.00 - 208.02 Acute Leukemia Of Unspecified Cell Type, Without Mention Of Having Achieved Remission - Acute Leukemia Of Unspecified Cell Type, In Relapse 208.10 - 208.12 Chronic Leukemia Of Unspecified Cell Type, Without Mention Of Having Achieved Remission - Chronic Leukemia Of Unspecified Cell Type, In Relapse 208.20 - 208.22 Subacute Leukemia Of Unspecified Cell Type, Without Mention Of Having Achieved Remission - Subacute Leukemia Of Unspecified Cell Type, In Relapse 208.80 – 208.82 Other Leukemia of Unspecified Cell Type, Without Mention of Having Achieved Remission – Other Leukemia of Unspecified Cell Type, In Relapse 208.90 - 208.92 Unspecified Leukemia, Without Mention Of Having Achieved Remission - Unspecified Leukemia, In Relapse 227.0 Benign Neoplasm Of Adrenal Gland 233.0 Carcinoma In Situ Of Breast 235.0 - 235.9 Neoplasm Of Uncertain Behavior Of Major Salivary Glands - Neoplasm Of Uncertain Behavior Of Other And Unspecified Respiratory Organs 236.0 Neoplasm Of Uncertain Behavior Of Uterus 236.2 Neoplasm Of Uncertain Behavior Of Ovary 236.3 Neoplasm Of Uncertain Behavior Of Other And Unspecified Female Genital Organs 236.4 Neoplasm Of Uncertain Behavior Of Testis 236.5 Neoplasm Of Uncertain Behavior Of Prostate 236.6 Neoplasm Of Uncertain Behavior Of Other And Unspecified Male Genital Organs 236.7 Neoplasm Of Uncertain Behavior Of Bladder 238.1 Neoplasm Of Uncertain Behavior Of Connective And Other Soft Tissue This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 16 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 238.2 Neoplasm Of Uncertain Behavior Of Skin 238.3 Neoplasm Of Uncertain Behavior Of Breast 238.71 - 238.77 Essential Thrombocythemia - Post-Transplant Lymphoproliferative Disorder (Ptld) 238.79 Other Lymphatic And Hematopoietic Tissues 238.8 Neoplasm Of Uncertain Behavior Of Other Specified Sites 259.2 Carcinoid Syndrome 273.1 - 273.3 Monoclonal Paraproteinemia - Macroglobulinemia 273.8 - 273.9 Other Disorders Of Plasma Protein Metabolism – Unspecified Disorder Of Plasma Protein Metabolism 279.00 - 279.06 Hypogammaglobulinemia Unspecified - Common Variable Immunodeficiency 279.09 Other Deficiency Of Humoral Immunity 279.10 - 279.13 Immunodeficiency With Predominant T-Cell Defect Unspecified - Nezelof's Syndrome 279.19 Other Deficiency Of Cell-Mediated Immunity 279.2 279.3 279.41 279.49 279.50 - 279.53 279.8 - 279.9 282.0 282.1 282.40 282.43 282.44 282.45 282.46 Combined Immunity Deficiency Unspecified Immunity Deficiency Autoimmune Lymphoproliferative Syndrome Autoimmune Disease, Not Elsewhere Classified Graft-Versus-Host Disease, Unspecified - Acute On Chronic Graft-Versus-Host Disease Other Specified Disorders Involving The Immune Mechanism - Unspecified Disorder Of Immune Mechanism Hereditary Spherocytosis Hereditary Elliptocytosis Thalassemia, Unspecified Alpha Thalassemia Beta Thalassemia Delta-Beta Thalassemia Thalassemia Minor This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 17 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 282.47 Hemoglobin E-Beta Thalassemia 282.5 Sickle-Cell Trait 282.60 - 282.64 Sickle-Cell Disease Unspecified - Sickle-Cell/Hb C Disease With Crisis 282.68 Other Sickle-Cell Disease Without Crisis 282.69 Other Sickle-Cell Disease With Crisis 282.7 Other Hemoglobinopathies 283.2 Hemoglobinuria Due To Hemolysis From External Causes 283.9 Acquired Hemolytic Anemia Unspecified 284.01 Constitutional Red Blood Cell Aplasia 284.09 Other Constitutional Aplastic Anemia 284.11 Antineoplastic Chemotherapy Induced Pancytopenia 284.12 Other Drug Induced Pancytopenia 284.19 Other Pancytopenia 284.2 Myelophthisis 284.81 Red Cell Aplasia (Acquired) (Adult) (With Thymoma) 284.89 Other Specified Aplastic Anemias 284.9 285.0 285.22 285.8 - 285.9 287.1 287.30 - 287.33 Aplastic Anemia Unspecified Sideroblastic Anemia Anemia In Neoplastic Disease Other Specified Anemias - Anemia Unspecified Qualitative Platelet Defects Primary Thrombocytopenia,Unspecified - Congenital And Hereditary Thrombocytopenic Purpura 287.39 Other Primary Thrombocytopenia 287.5 Thrombocytopenia Unspecified 288.00 - 288.04 Neutropenia, Unspecified - Neutropenia Due To Infection 288.09 Other Neutropenia 288.1 - 288.4 Functional Disorders Of Polymorphonuclear Neutrophils – Hemophagocytic Syndromes 288.50 - 288.51 Leukocytopenia, Unspecified - Lymphocytopenia This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 18 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 288.59 Other Decreased White Blood Cell Count 288.60 - 288.65 Leukocytosis, Unspecified - Basophilia 288.69 Other Elevated White Blood Cell Count 288.8 - 288.9 Other Specified Disease Of White Blood Cells – Unspecified Disease Of White Blood Cells 289.4 Hypersplenism 289.50 - 289.53 Disease Of Spleen Unspecified - Neutropenic Splenomegaly 289.59 Other Diseases Of Spleen 289.83 Myelofibrosis 289.9 Unspecified Diseases Of Blood And Blood-Forming Organs 364.3 Unspecified Iridocyclitis 452 Portal Vein Thrombosis 453.9 Embolism And Thrombosis Of Unspecified Site 555.0 - 555.2 555.9 556.0 - 556.6 556.9 630 696.0 714.30 720.0 - 720.2 720.81 720.89 Regional Enteritis Of Small Intestine - Regional Enteritis Of Small Intestine With Large Intestine Regional Enteritis Of Unspecified Site Ulcerative (Chronic) Enterocolitis - Universal Ulcerative (Chronic) Colitis Ulcerative Colitis Unspecified Hydatidiform Mole Psoriatic Arthropathy Chronic Or Unspecified Polyarticular Juvenile Rheumatoid Arthritis Ankylosing Spondylitis - Sacroiliitis Not Elsewhere Classified Inflammatory Spondylopathies In Diseases Classified Elsewhere Other Inflammatory Spondylopathies This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L30692 Flow Cytometry (Page 19 of 19) Data Source: www.cms.com Testing performed by Quest Diagnostics Nichols Institute – San Juan Capistrano, CA CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Palmetto GBA does NOT consider it “reasonable and necessary” to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. ICD-9-CM Codes that Support Medical Necessity The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 720.9 785.6 789.2 Unspecified Inflammatory Spondylopathy Enlargement Of Lymph Nodes Splenomegaly 789.30 - 789.37 Abdominal Or Pelvic Swelling Mass Or Lump Unspecified Site - Abdominal Or Pelvic Swelling Mass Or Lump Generalized 789.39 Abdominal Or Pelvic Swelling Mass Or Lump Other Specified Site 791.0 Proteinuria 795.4 Other Nonspecific Abnormal Histological Findings 996.80 - 996.87 Complications Of Unspecified Transplanted Organ – Complications Of Transplanted Organ Intestine 996.88 Complications Of Transplanted Organ, Stem Cell 996.89 Complications Of Other Specified Transplanted Organ V08 Asymptomatic Human Immunodeficiency Virus (Hiv) Infection Status V10.60 - V10.63 Personal History Of Unspecified Leukemia - Personal History Of Monocytic Leukemia V10.69 Personal History Of Other Leukemia V42.0 - V42.7 Kidney Replaced By Transplant - Liver Replaced By Transplant V42.81 - V42.84 Bone Marrow Replaced By Transplant - Organ Or Tissue Replaced By Transplant Intestines V42.89 Other Specified Organ Or Tissue Replaced By Transplant V42.9 Unspecified Organ Or Tissue Replaced By Transplant V49.83 Awaiting Organ Transplant Status V58.44 Aftercare Following Organ Transplant V71.1 Observation For Suspected Malignant Neoplasm This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32731 Frequency of Laboratory Tests – Glucose Testing CPT Codes: 82948, 82962 Data Source: http://www.novitas-solutions.com LCD Description: This LCD imposes utilization guideline limitations. Despite Medicare's allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services. LCD Frequency Limit: Once per month. Acceptable Reasons (ICD-9-CM Codes) for Exceeding the LCD Maximum: • Uncontrolled Diabetes MellitusThyrotoxicosis Codes pertaining to the above bullets: 250.02-250.03 250.92-250.93 This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32731 Frequency of Laboratory Tests - Lipids CPT Codes: 80061, 82465, 83718, 83721, 84478 Data Source: http://www.novitas-solutions.com LCD Description: This LCD imposes utilization guideline limitations. Despite Medicare's allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services. LCD Frequency Limit: No more than every two months for any test (e.g. triglycerides, LDL cholesterol), whether ordered in a panel or separately ordered. Acceptable Reasons (ICD-9-CM Codes) for Exceeding the LCD Maximum: 577.0 – 577.1 Pancreatitis V58.69 Inability To Stabilize Lipid-Lowering Drug Dosing V58.69 Adverse Reaction To Lipid-Lowering Drug This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32731 Frequency of Laboratory Tests – Thyroid Testing CPT Codes: 84436, 84439, 84443, 84479 Data Source: http://www.novitas-solutions.com LCD Description: This LCD imposes utilization guideline limitations. Despite Medicare's allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services. LCD Frequency Limit: Four times a year for most patients, except for selected endocrine presentations. Acceptable Reasons (ICD-9-CM Codes) for Exceeding the LCD Maximum: • • • • Inability To Stabilize Thyroid Medication Dosing Thyrotoxicosis Concurrent Endocrinopathies Hypothyroidism Codes pertaining to the above bullets: 226 242.00 – 242.91 243 244.0 – 244.3 244.8 – 244.9 245.0 – 245.4 245.8 – 245.9 250.00 – 250.03 250.10 – 250.13 250.20 – 250.23 250.30 – 250.33 250.40 – 250.43 250.50 – 250.53 250.60 – 250.63 250.70 – 250.73 250.80 – 250.83 250.90 – 250.93 252.1 253.2 253.4 255.2 255.41 – 255.42 272.0 272.2 275.40 – 275.42 275.49 276.0 – 276.1 279.4 281.0 281.9 285.9 290.0 290.10 – 290.13 290.20 – 290.21 290.3 293.0 – 293.1 296.00 – 296.06 296.10 – 296.16 296.20 – 296.26 296.30 – 296.36 296.40 – 296.46 296.50 – 296.56 296.60 – 296.66 296.7 296.80 – 296.82 296.89 296.90 296.99 300.00 – 300.02 300.09 311 359.5 374.41 374.82 376.21 – 376.22 427.0 427.31 428.0 511.9 560.1 625.3 750.15 780.02 780.09 783.1 783.21 784.1 785.0 – 785.1 794.5 V58.69 This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas Data Source: http://www.novitas-solutions.com L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (Page 1 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 076.0 - 076.1 076.9 077.0 077.98 - 077.99 098.0 098.10 - 098.17 098.19 098.2 098.30 - 098.37 098.39 098.40 - 098.43 098.49 098.50 - 098.53 098.59 Trachoma Initial Stage - Trachoma Active Stage Trachoma Unspecified Inclusion Conjunctivitis Unspecified Diseases Of Conjunctiva Due To Chlamydiae - Unspecified Diseases Of Conjunctiva Due To Viruses Gonococcal Infection (Acute) Of Lower Genitourinary Tract Gonococcal Infection (Acute) Of Upper Genitourinary Tract Site Unspecified - Gonococcal Salpingitis Specified As Acute Other Gonococcal Infection (Acute) Of Upper Genitourinary Tract Gonococcal Infection Chronic Of Lower Genitourinary Tract Chronic Gonococcal Infection Of Upper Genitourinary Tract Site Unspecified - Gonococcal Salpingitis (Chronic) Other Chronic Gonococcal Infection Of Upper Genitourinary Tract Gonococcal Conjunctivitis (Neonatorum) - Gonococcal Keratitis Other Gonococcal Infection Of Eye Gonococcal Arthritis - Gonococcal Spondylitis Other Gonococcal Infection Of Joint This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/05/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas Data Source: http://www.novitas-solutions.com L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (Page 2 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 098.6 - 098.7 098.81 - 098.86 098.89 099.1 099.3 099.41 099.50 - 099.56 Gonococcal Infection Of Pharynx - Gonococcal Infection Of Anus And Rectum Gonococcal Keratosis (Blennorrhagica) - Gonococcal Peritonitis Gonococcal Infection Of Other Specified Sites Lymphogranuloma Venereum Reiter's Disease Other Nongonococcal Urethritis Chlamydia Trachomatis Other Venereal Diseases Due To Chlamydia Trachomatis Unspecified Site - Other Venereal Diseases Due To Chlamydia Trachomatis Peritoneum 099.59 Other Venereal Diseases Due To Chlamydia Trachomatis Other Specified Site 112.1 - 112.2 Candidiasis Of Vulva And Vagina - Candidiasis Of Other Urogenital Sites 131.00 - 131.03 Urogenital Trichomoniasis Unspecified - Trichomonal Prostatitis 131.09 Other Urogenital Trichomoniasis 131.8 - 131.9 Trichomoniasis Of Other Specified Sites - Trichomoniasis Unspecified 288.00 - 288.04 Neutropenia, Unspecified - Neutropenia Due To Infection 288.09 Other Neutropenia 288.66 Bandemia 288.8 Other Specified Disease Of White Blood Cells This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/05/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas Data Source: http://www.novitas-solutions.com L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (Page 3 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 289.1 289.53 289.83 372.00 372.02 - 372.03 372.10 - 372.12 595.4 597.80 - 597.81 601.0 601.8 - 601.9 604.0 604.90 - 604.91 608.89 614.0 614.2 - 614.4 614.6 Chronic Lymphadenitis Neutropenic Splenomegaly Myelofibrosis Acute Conjunctivitis Unspecified Acute Follicular Conjunctivitis - Other Mucopurulent Conjunctivitis Chronic Conjunctivitis Unspecified - Chronic Follicular Conjunctivitis Cystitis In Diseases Classified Elsewhere Urethritis Unspecified - Urethral Syndrome Nos Acute Prostatitis Other Specified Inflammatory Diseases Of Prostate - Prostatitis Unspecified Orchitis Epididymitis And Epididymo-Orchitis With Abscess Orchitis And Epididymitis Unspecified - Orchitis And Epididymitis In Diseases Classified Elsewhere Other Specified Disorders Of Male Genital Organs Acute Salpingitis And Oophoritis Salpingitis And Oophoritis Not Specified As Acute Subacute Or Chronic - Chronic Or Unspecified Parametritis And Pelvic Cellulitis Pelvic Peritoneal Adhesions Female (Postoperative) (Postinfection) This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/05/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas Data Source: http://www.novitas-solutions.com L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (Page 4 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 614.8 - 614.9 616.0 616.10 616.11 616.2 616.3 616.4 616.50 616.51 616.81 616.89 616.9 628.2 629.89 683 Other Specified Inflammatory Disease Of Female Pelvic Organs And Tissues - Unspecified Inflammatory Disease Of Female Pelvic Organs And Tissues Cervicitis And Endocervicitis Vaginitis And Vulvovaginitis Unspecified Vaginitis And Vulvovaginitis In Diseases Classified Elsewhere Cyst Of Bartholin's Gland Abscess Of Bartholin's Gland Other Abscess Of Vulva Ulceration Of Vulva Unspecified Ulceration Of Vulva In Diseases Classified Elsewhere Mucositis (Ulcerative) Of Cervix, Vagina, And Vulva Other Inflammatory Disease Of Cervix, Vagina And Vulva Unspecified Inflammatory Disease Of Cervix Vagina And Vulva Infertility Female Of Tubal Origin Other Specified Disorders Of Female Genital Organs Acute Lymphadenitis This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/05/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Texas Data Source: http://www.novitas-solutions.com L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (Page 5 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 711.90 - 711.99 716.50 - 716.59 716.60 - 716.68 716.90 - 716.99 719.40 - 719.49 727.00 727.05 - 727.06 727.09 771.6 780.60 - 780.61 782.1 785.6 788.1 788.64 - 788.65 788.7 789.00 - 789.07 Unspecified Infective Arthritis Site Unspecified - Unspecified Infective Arthritis Involving Multiple Sites Unspecified Polyarthropathy Or Polyarthritis Site Unspecified - Unspecified Polyarthropathy Or Polyarthritis Involving Multiple Sites Unspecified Monoarthritis Site Unspecified - Unspecified Monoarthritis Involving Other Specified Sites Unspecified Arthropathy Site Unspecified - Unspecified Arthropathy Involving Multiple Sites Pain In Joint Site Unspecified - Pain In Joint Involving Multiple Sites Synovitis And Tenosynovitis Unspecified Other Tenosynovitis Of Hand And Wrist - Tenosynovitis Of Foot And Ankle Other Synovitis And Tenosynovitis Neonatal Conjunctivitis And Dacryocystitis Fever, Unspecified - Fever Presenting With Conditions Classified Elsewhere Rash And Other Nonspecific Skin Eruption Enlargement Of Lymph Nodes Dysuria Urinary Hesitancy - Straining On Urination Urethral Discharge Abdominal Pain Unspecified Site - Abdominal Pain Generalized This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/05/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy – Texas Data Source: http://www.novitas-solutions.com L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (Page 6 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 711.90 - 711.99 716.50 - 716.59 716.60 - 716.68 716.90 - 716.99 719.40 - 719.49 727.00 727.05 - 727.06 727.09 771.6 780.60 - 780.61 782.1 785.6 788.1 788.64 - 788.65 788.7 789.00 - 789.07 Unspecified Infective Arthritis Site Unspecified - Unspecified Infective Arthritis Involving Multiple Sites Unspecified Polyarthropathy Or Polyarthritis Site Unspecified - Unspecified Polyarthropathy Or Polyarthritis Involving Multiple Sites Unspecified Monoarthritis Site Unspecified - Unspecified Monoarthritis Involving Other Specified Sites Unspecified Arthropathy Site Unspecified - Unspecified Arthropathy Involving Multiple Sites Pain In Joint Site Unspecified - Pain In Joint Involving Multiple Sites Synovitis And Tenosynovitis Unspecified Other Tenosynovitis Of Hand And Wrist - Tenosynovitis Of Foot And Ankle Other Synovitis And Tenosynovitis Neonatal Conjunctivitis And Dacryocystitis Fever, Unspecified - Fever Presenting With Conditions Classified Elsewhere Rash And Other Nonspecific Skin Eruption Enlargement Of Lymph Nodes Dysuria Urinary Hesitancy - Straining On Urination Urethral Discharge Abdominal Pain Unspecified Site - Abdominal Pain Generalized This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/05/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Data Source: http://www.novitas-solutions.com Medicare Local Coverage Determination Policy – Texas L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (Page 7 of 7) CPT Codes: 87481, 87798 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. Utilization Guidelines: No more than two individual microorganisms may be concurrently billed for CPT 87481 and 87798. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 87481 and 87798 are considered on a case by case basis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 12/05/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L32636 – MyPRS Genetic Expression Profile Testing CPT Codes: 86849 Data Source: http://www.novitas-solutions.com LCD Description: Multiple Myeloma Gene Expression Profile (MyPRS) isolates plasma cells from myeloma patients, extracts DNA, which is then subjected to MicroArray testing and application of validated software programs to identifying patterns of genetic abnormalities. Seventy highly predictive genes have been identified and correlated to myeloma early relapse. MyPRS gives a predictive risk signature as high-risk or low-risk at this time. A high risk score predicts a <20% three-year complete remission where as a low-risk predicts a five-year complete remission of > 60%. The predictive value for the stratification of therapeutic interventions allows these patients to be treated in a more personalized manner based on their own genetic profile. However, it would be inappropriate to use this test as a diagnostic tool or as a monitoring device of ongoing therapy. Other testing is available for this function. This test is used only after the initial diagnosis of multiple myeloma has been made and will be available to be used in the stratification of therapeutic interventions. The coverage is set to include only two clinical settings: 1.) Once after initial diagnosis is made (ICD-9-CM 203.00). In the event MyPRS was not tested at diagnosis of myeloma and there is ongoing initial therapy with persistent disease, MyPRS can be done still as an initial test. Or 2.) if relapse has occurred and a change in the therapeutic modalities is contemplated (ICD-9-CM 203.02). ICD-9-CM Codes that Support Medical Necessity The MyPRS test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 203.00 Multiple Myeloma, Without Mention Of Having Achieved Remission 203.02 Multiple Myeloma, In Relapse This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L34352 Qualitative Drug Screening (Page 1 of 2) Data Source: http://www.novitas-solutions.com CPT Codes: 80102, G0431, G0434 LCD Description: A qualitative drug screen may be indicated with a symptomatic patient when the history is unreliable, with a multiple-drug ingestion, with a patient in delirium or coma, for the identification of specific drugs, and to indicate when antagonists may be used. The clinical utility of drug screens in the emergency setting may be limited because patient management decisions are unaffected since most therapy for drug poisonings is symptom directed and supportive. Utilization Guidelines: Drug screening for medico-legal purposes (e.g., court-ordered drug screening) or for employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment) is not covered. ICD-9-CM Codes that Support Medical Necessity The Qualitative Drug Screening test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 276.2 295.00 295.10 295.20 295.30 304.01 304.90 305.90 345.10 345.11 345.3 345.90 345.91 426.10 426.11 426.12 426.13 426.82 Acidosis Simple Type Schizophrenia Unspecified State Disorganized Type Schizophrenia Unspecified State Catatonic Type Schizophrenia Unspecified State Paranoid Type Schizophrenia Unspecified State Opioid Type Dependence Continuous Use Unspecified Drug Dependence Unspecified Use Other Mixed Or Unspecified Drug Abuse Unspecified Use Generalized Convulsive Epilepsy Without Intractable Epilepsy Generalized Convulsive Epilepsy With Intractable Epilepsy Grand Mal Status Epileptic Epilepsy Unspecified Without Intractable Epilepsy Epilepsy Unspecified With Intractable Epilepsy Atrioventricular Block Unspecified First Degree Atrioventricular Block Mobitz (Type) Ii Atrioventricular Block Other Second Degree Atrioventricular Block Long Qt Syndrome 427.0 427.1 780.01 780.09 780.1 780.39 780.97 963.0 965.00 965.01 965.02 965.09 965.1 965.4 965.5 965.61 966.1 967.0 Paroxysmal Supraventricular Tachycardia Paroxysmal Ventricular Tachycardia Coma Alteration Of Consciousness Other Hallucinations Other Convulsions Altered Mental Status Poisoning By Antiallergic And Antiemetic Drugs Poisoning By Opium (Alkaloids) Unspecified Poisoning By Heroin Poisoning By Methadone Poisoning By Other Opiates And Related Narcotics Poisoning By Salicylates Poisoning By Aromatic Analgesics Not Elsewhere Classified Poisoning By Pyrazole Derivatives Poisoning By Propionic Acid Derivatives Poisoning By Hydantoin Derivatives Poisoning By Barbiturates This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy - Texas L34352 Qualitative Drug Screening (Page 2 of 2) Data Source: http://www.novitas-solutions.com CPT Codes: 80102, G0431, G0434 LCD Description: A qualitative drug screen may be indicated with a symptomatic patient when the history is unreliable, with a multiple-drug ingestion, with a patient in delirium or coma, for the identification of specific drugs, and to indicate when antagonists may be used. The clinical utility of drug screens in the emergency setting may be limited because patient management decisions are unaffected since most therapy for drug poisonings is symptom directed and supportive. Utilization Guidelines: Drug screening for medico-legal purposes (e.g., court-ordered drug screening) or for employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment) is not covered. ICD-9-CM Codes that Support Medical Necessity The Qualitative Drug Screening test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided. 967.1 967.2 967.2 967.3 967.4 967.5 967.6 967.8 967.9 969.00 969.01 969.02 969.03 969.04 969.05 969.09 969.1 969.2 Poisoning By Chloral Hydrate Group Poisoning By Paraldehyde Poisoning By Paraldehyde Poisoning By Bromine Compounds Poisoning By Methaqualone Compounds Poisoning By Glutethimide Group Poisoning By Mixed Sedatives Not Elsewhere Classified Poisoning By Other Sedatives And Hypnotics Poisoning By Unspecified Sedative Or Hypnotic Poisoning By Antidepressant, Unspecified Poisoning By Monoamine Oxidase Inhibitors Poisoning By Selective Serotonin And Norepinephrine Reuptake Inhibitors Poisoning By Selective Serotonin Reuptake Inhibitors Poisoning By Tetracyclic Antidepressants Poisoning By Tricyclic Antidepressants Poisoning By Other Antidepressants Poisoning By Phenothiazine-Based Tranquilizers Poisoning By Butyrophenone-Based Tranquilizers 969.3 969.4 969.5 969.6 969.70 969.71 969.72 969.73 969.79 969.8 969.9 970.81 970.89 972.1 977.9 V15.81 V58.69 Poisoning By Other Antipsychotics Neuroleptics And Major Tranquilizers Poisoning By Benzodiazepine-Based Tranquilizers Poisoning By Other Tranquilizers Poisoning By Psychodysleptics (Hallucinogens) Poisoning By Psychostimulant, Unspecified Poisoning By Caffeine Poisoning By Amphetamines Poisoning By Methylphenidate Poisoning By Other Psychostimulants Poisoning By Other Specified Psychotropic Agents Poisoning By Unspecified Psychotropic Agent Poisoning By Cocaine Poisoning By Other Central Nervous System Stimulants Poisoning By Cardiotonic Glycosides And Drugs Of Similar Action Poisoning By Unspecified Drug Or Medicinal Substance Personal History Of Noncompliance With Medical Treatment Presenting Hazards To Health Long-Term (Current) Use Of Other Medications This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 03/25/13 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
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