Medicare National and Local Coverage Determination Policy – DE, MD,...
Medicare National and Local Coverage Determination Policy – DE, MD, NJ, PA Policies in this MLCP Reference Guide apply to testing performed at a Quest Diagnostics facility and apply to Medicare National Coverage Determination Policy. This diagnosis code reference guide is provided as an aid to physicians and office staff in determining when an ABN (Advance Beneficiary Notice) is necessary. Diagnosis codes must be applicable to the patient’s symptoms or conditions and must be consistent with documentation in the patient’s medical record. Quest Diagnostics does not recommend any diagnosis codes and will only submit diagnosis information provided to us by the ordering physician or his/her designated staff. The CPT codes provided are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed. Please note this document has been updated with National Medicare changes effective 4/1/2012 • Click here for National MLCP Policies Tool Document contains information on National Medicare Limited Coverage Policies • • • • • • • • • • • • • • • • • • • • • • • Alpha-Fetoprotein Blood Counts Blood Glucose Testing Carcinoembryonic Antigen Collagen Crosslinks - Any Method Digoxin Therapeutic Drug Assay Fecal Occult Blood Gamma Glutamyl Transferase Glycated Hemoglobin - Glycated Protein Hepatitis Panel/Acute Hepatitis Panel Human Chorionic Gonadotropin Human Immunodeficiency Virus (HIV) Testing (Diagnosis) Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) Lipids Testing Partial Thromboplastin Time (PTT) Prostate Specific Antigen Prothrombin Time (PT) Serum Iron Studies Thyroid Testing Tumor Antigen by Immunoassay CA 15-3 CA 27.29 Tumor Antigen by Immunoassay CA 19-9 Tumor Antigen by Immunoassay CA-125 Urine Culture, Bacterial • Click policy below for Local MLCP Policy Tool Document contains the below Medicare Local Limited Coverage Policies for lab testing performed in DE, DC, MD, NJ, PA. • • • • • • • • • • • • • • • • • B-type Natriuretic Peptide (BNP) Assays C-Reactive Protein Testing Cyanocobalamin (Vitamin B-12) Cytogenetic Analysis Testing Debridement of Mycotic Nails Flow Cytometry Flow Cytometry:Cell Cycle or DNA Analysis ImmunoCAP(R) Radioallergosorbent Test, Fluoroallergosorbent Testing Moh’s Micrographic Surgery Molecular Diagnostics: Genitourinary Infectious Disease Molecular Diagnostics: Human Papillomavirus Molecular Diagnostics: Not otherwise specified OVA-1 Assay Parathormone (Parathyroid Hormone) Qaulitative Drug Testing Vitamin D: 25 Hydroxy Vitamin D: 1,25 Dihydroxy 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: 1/01/12 Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) B-type Natriuretic Peptide (BNP) Assays (1 of 2) CPT Code: 83880 Data Source: https://www.novitas-solutions.com LCD Description: B-type natriuretic peptide (BNP), a naturally occurring hormone, is secreted primarily in response to pressure and volume overload in the heart. BNP measurements may be considered reasonable and necessary when used in combination with other clinical data such as medical history, physical examination, laboratory studies, chest x-ray, and electrocardiography. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 402.01 402.11 402.91 404.01 404.03 404.11 MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 404.13 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 404.91 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 404.93 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 410.00 – 410.92ACUTE MYOCARDIAL INFARCTION OF A NTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL I NFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE 411.1 INTERMEDIATE CORONARY SYNDROME 415.0 ACUTE COR PULMONALE 416.0 PRIMARY PULMONARY HYPERTENSION 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) B-type Natriuretic Peptide (BNP) Assays (2 of 2) CPT Code: 83880 Data Source: https://www.novitas-solutions.com LCD Description: B-type natriuretic peptide (BNP), a naturally occurring hormone, is secreted primarily in response to pressure and volume overload in the heart. BNP measurements may be considered reasonable and necessary when used in combination with other clinical data such as medical history, physical examination, laboratory studies, chest x-ray, and electrocardiography. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 423.2 425.11 CONSTRICTIVE PERICARDITIS HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY 425.18 OTHER HYPERTROPHIC CARDIOMYOPATHY 425.4 OTHER PRIMARY CARDIOMYOPATHIES 428.0 - 428.1 CONGESTIVE HEART FAILURE UNSPECIFIED – LEFT HEART FAILURE 428.20 - 428.23 UNSPECIFIED SYSTOLIC HEART FAILURE - ACUTE ON CHRONIC SYSTOLIC HEART FAILURE 428.30 - 428.33 UNSPECIFIED DIASTOLIC HEART FAILURE ACUTE ON CHRONIC DIASTOLIC HEART FAILURE 428.40 - 428.43 UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 428.9 HEART FAILURE UNSPECIFIED 493.01 - 493.02 EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS - EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION 493.11 - 493.12 INTRINSIC ASTHMA WITH STATUS ASTHMATICUS - INTRINSIC ASTHMA WITH (ACUTE) ACERBATION 493.21 - 493.22 CHRONIC OBSTRUCTIVE ASTHMA WITH STATUS ASTHMATICUS - CHRONIC OBSTRUCTIVE ASTHMA WITH (ACUTE) EXACERBATION 493.81 - 493.82 EXERCISE-INDUCED BRONCHOSPASM - COUGH VARIANT ASTHMA 493.91 - 493.92 ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS - ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION 782.3 EDEMA 786.00 RESPIRATORY ABNORMALITY UNSPECIFIED 786.02 ORTHOPNEA 786.05 SHORTNESS OF BREATH 786.06 TACHYPNEA 786.07 WHEEZING 786.09 RESPIRATORY ABNORMALITY OTHER 786.7 ABNORMAL CHEST SOUNDS Utilization Guidelines As a diagnostic test, BNP testing is not expected to be performed more than four times in a 12 month period in the non-facility setting. The use of BNP for monitoring CHF is not covered. 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) C-Reactive Protein Testing CPT Code: 86141 Data Source: https://www.novitas-solutions.com LCD Description: C-Reactive Protein, (CRP), is a nonspecific, acute-phase reactant produced in response to tissue injury, inflammation or infection. As an acute phase reactant, concentrations rise rapidly and half-life is short. Recent studies have shown that chronic, low-grade inflammation contributes to atherogenesis and the development of coronary artery disease (CAD). Inflammatory changes lead to progressive disease, which culminates in plaque instability, rupture, thrombosis, and myocardial infarction (MI). 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 272.0 272.1 272.2 272.3 272.4 414.01 V49.89* PURE HYPERCHOLESTEROLEMIA PURE HYPERGLYCERIDEMIA MIXED HYPERLIPIDEMIA HYPERCHYLOMICRONEMIA OTHER AND UNSPECIFIED HYPERLIPIDEMIA CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY OTHER SPECIFIED CONDITIONS INFLUENCING HEALTH STATUS Note: per Novitas Medicare LCD policy *Use ICD-9-CM code V49.89 for patients at intermediate risk for CAD who do not have elevated lipids (i.e., do not meet criteria to use ICD-9-CM codes 272.0-272.4) Utilization Guidelines Generally, the measurement of hsCRP markers is performed twice (averaging results), optimally two weeks apart and fasting or nonfasting, with the average expressed in mg/L, in metabolically stable patients. If an average CRP level of >10.0 mg/L is found on two tests performed 2 weeks apart, a third test may be performed after ruling out possible infectious or inflammatory causes for the increase (AHA/CDC Recommendation). 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) CYANOCOBALAMIN (VITAMIN B-12) (1 of 3) CPT Code: 82607 Data Source: https://www.novitas-solutions.com LCD Description: The serum cyanocobalamin is a quantitative analysis of serum Vitamin B12 levels. It is generally indicated in the evaluation of macrocytic anemias whose cause is unknown, and in patients with malabsorptive states. Vitamin B12 (and / or folate) deficiency may be present when one or more of the following findings are present: oval macrocytic red blood cells on peripheral blood smear, with or without anemia; hypersegmented neutrophils on peripheral blood smear; pancytopenia of uncertain cause (anemia, thrombocytopenia, and neutropenia), unexplained neurologic signs and symptoms: especially dementia, weakness, sensory ataxia, paresthesias (e.g., suspected subacute combined degeneration), or increased risk for deficiency due to alcoholism, malnutrition, strict vegan diet, malabsorption, certain medications. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 040.2 123.4 151.0 - 151.9 152.0 - 152.9 157.0 - 157.9 197.4 197.8 261 262 263.0 263.2 263.8 - 263.9 WHIPPLE'S DISEASE DIPHYLLOBOTHRIASIS INTESTINAL MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE MALIGNANT NEOPLASM OF DUODENUM - MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE MALIGNANT NEOPLASM OF HEAD OF PANCREAS MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED SECONDARY MALIGNANT NEOPLASM OF SMALL INTESTINE INCLUDING DUODENUM SECONDARY MALIGNANT NEOPLASM OF OTHER DIGESTIVE ORGANS AND SPLEEN NUTRITIONAL MARASMUS OTHER SEVERE PROTEIN-CALORIE MALNUTRITION MALNUTRITION OF MODERATE DEGREE ARRESTED DEVELOPMENT FOLLOWING PROTEINCALORIE MALNUTRITION OTHER PROTEIN-CALORIE MALNUTRITION UNSPECIFIED PROTEIN-CALORIE MALNUTRITION 266.2 270.4 281.0 - 281.3 281.9 284.11 284.12 284.19 285.21 285.9 290.0 290.10 290.41 290.42 290.43 OTHER B-COMPLEX DEFICIENCIES DISTURBANCES OF SULPHUR-BEARING AMINO-ACID METABOLISM PERNICIOUS ANEMIA - OTHER SPECIFIED MEGALOBLASTIC ANEMIAS NOT ELSEWHERE CLASSIFIED UNSPECIFIED DEFICIENCY ANEMIA ANTINEOPLASTIC CHEMOTHERAPY INDUCED PANCYTOPENIA OTHER DRUG INDUCED PANCYTOPENIA OTHER PANCYTOPENIA ANEMIA IN CHRONIC KIDNEY DISEASE ANEMIA UNSPECIFIED SENILE DEMENTIA UNCOMPLICATED PRESENILE DEMENTIA UNCOMPLICATED VASCULAR DEMENTIA, WITH DELIRIUM VASCULAR DEMENTIA, WITH DELUSIONS VASCULAR DEMENTIA, WITH DEPRESSED MOOD 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) CYANOCOBALAMIN (VITAMIN B-12) (2 of 3) CPT Code: 82607 Data Source: https://www.novitas-solutions.com LCD Description: The serum cyanocobalamin is a quantitative analysis of serum Vitamin B12 levels. It is generally indicated in the evaluation of macrocytic anemias whose cause is unknown, and in patients with malabsorptive states. Vitamin B12 (and / or folate) deficiency may be present when one or more of the following findings are present: oval macrocytic red blood cells on peripheral blood smear, with or without anemia; hypersegmented neutrophils on peripheral blood smear; pancytopenia of uncertain cause (anemia, thrombocytopenia, and neutropenia), unexplained neurologic signs and symptoms: especially dementia, weakness, sensory ataxia, paresthesias (e.g., suspected subacute combined degeneration), or increased risk for deficiency due to alcoholism, malnutrition, strict vegan diet, malabsorption, certain medications. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 291.1 291.2 293.0 294.10 294.11 294.20 294.21 294.8 303.91 331.6 ALCOHOL-INDUCED PERSISTING AMNESTIC DISORDER ALCOHOL-INDUCED PERSISTING DEMENTIA DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITHOUT BEHAVIORAL DISTURBANCE DEMENTIA IN CONDITIONS CLASSIFIED ELSEWHERE WITH BEHAVIORAL DISTURBANCE DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE DEMENTIA, UNSPECIFIED, WITH BEHAVIORAL DISTURBANCE OTHER PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE CONTINUOUS DRINKING BEHAVIOR CORTICOBASAL DEGENERATION 331.7 331.83 334.4 354.8 - 354.9 355.8 - 355.9 356.4 356.9 377.33 377.34 529.0 529.4 529.6 CEREBRAL DEGENERATION IN DISEASES CLASSIFIED ELSEWHERE MILD COGNITIVE IMPAIRMENT, SO STATED CEREBELLAR ATAXIA IN DISEASES CLASSIFIED ELSEWHERE OTHER MONONEURITIS OF UPPER LIMB MONONEURITIS OF UPPER LIMB UNSPECIFIED MONONEURITIS OF LOWER LIMB UNSPECIFIED - MONONEURITIS OF UNSPECIFIED SITE IDIOPATHIC PROGRESSIVE POLYNEUROPATHY UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY NUTRITIONAL OPTIC NEUROPATHY TOXIC OPTIC NEUROPATHY GLOSSITIS ATROPHY OF TONGUE PAPILLAE GLOSSODYNIA 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) CYANOCOBALAMIN (VITAMIN B-12) (3 of 3) CPT Code: 82607 Data Source: https://www.novitas-solutions.com LCD Description: The serum cyanocobalamin is a quantitative analysis of serum Vitamin B12 levels. It is generally indicated in the evaluation of macrocytic anemias whose cause is unknown, and in patients with malabsorptive states. Vitamin B12 (and / or folate) deficiency may be present when one or more of the following findings are present: oval macrocytic red blood cells on peripheral blood smear, with or without anemia; hypersegmented neutrophils on peripheral blood smear; pancytopenia of uncertain cause (anemia, thrombocytopenia, and neutropenia), unexplained neurologic signs and symptoms: especially dementia, weakness, sensory ataxia, paresthesias (e.g., suspected subacute combined degeneration), or increased risk for deficiency due to alcoholism, malnutrition, strict vegan diet, malabsorption, certain medications. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 535.10 - 535.11 ATROPHIC GASTRITIS (WITHOUT HEMORRHAGE) - ATROPHIC GASTRITIS WITH HEMORRHAGE 536.0 ACHLORHYDRIA 555.0 - 555.9 REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF UNSPECIFIED SITE 564.2 POSTGASTRIC SURGERY SYNDROMES 577.1 CHRONIC PANCREATITIS 579.0 - 579.9 CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION 751.1 CONGENITAL ATRESIA AND STENOSIS OF SMALL INTESTINE 780.93 MEMORY LOSS 780.97 ALTERED MENTAL STATUS 781.2 ABNORMALITY OF GAIT 781.3 LACK OF COORDINATION 782.0 DISTURBANCE OF SKIN SENSATION V10.00 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN GASTROINTESTINAL TRACT V10.04 V10.09 V12.1 V44.1 V44.2 V44.4 V45.3 V45.72 V45.75 V45.86 V58.69 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF STOMACH PERSONAL HISTORY OF MALIGNANT NEOPLASM OF OTHER SITES IN GASTROINTESTINAL TRACT PERSONAL HISTORY OF NUTRITIONAL DEFICIENCY GASTROSTOMY STATUS ILEOSTOMY STATUS STATUS OF OTHER ARTIFICIAL OPENING OF GASTROINTESTINAL TRACT POSTSURGICAL INTESTINAL BYPASS OR ANASTOMOSIS STATUS ACQUIRED ABSENCE OF INTESTINE (LARGE) (SMALL) ACQUIRED ABSENCE OF ORGAN STOMACH BARIATRIC SURGERY STATUS 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Data Source: https://www.novitas-solutions.com Cytogenetic Analysis Testing (Page 1 of 7) CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88299, 88365, 88367, 88368 LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques, and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 140.0 - 140.9 141.0 - 141.9 142.0 - 142.9 143.0 - 143.9 150.0 - 150.9 151.0 - 151.9 152.1 - 152.8 158.0 162.0 - 165.9 MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER MALIGNANT NEOPLASM OF BASE OF TONGUE MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED MALIGNANT NEOPLASM OF PAROTID GLAND MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED MALIGNANT NEOPLASM OF UPPER GUM MALIGNANT NEOPLASM OF GUM UNSPECIFIED MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE MALIGNANT NEOPLASM OF JEJUNUM - MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SMALL INTESTINE MALIGNANT NEOPLASM OF RETROPERITONEUM MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE RESPIRATORY SYSTEM 170.0 - 170.9 MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE - MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED 171.0 - 171.9 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK - MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED 173.00 - 173.99 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP - OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED 174.0 - 174.9 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE 175.0 - 175.9 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST - MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST 183.0 MALIGNANT NEOPLASM OF OVARY 183.2 MALIGNANT NEOPLASM OF FALLOPIAN TUBE 183.3 MALIGNANT NEOPLASM OF BROAD LIGAMENT OF UTERUS 183.4 MALIGNANT NEOPLASM OF PARAMETRIUM 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Data Source: https://www.novitas-solutions.com Cytogenetic Analysis Testing (Page 2 of 7) CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88299, 88365, 88367, 88368 LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques, and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 183.5 183.8 183.9 188.0 - 188.9 189.0 - 189.9 190.1 191.0 - 191.9 192.3 194.0 - 194.9 197.0 - 197.8 MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER - MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS - MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED MALIGNANT NEOPLASM OF ORBIT MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE MALIGNANT NEOPLASM OF SPINAL MENINGES MALIGNANT NEOPLASM OF ADRENAL GLAND MALIGNANT NEOPLASM OF ENDOCRINE GLAND SITE UNSPECIFIED 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 200.00 - 202.98 RETICULOSARCOMA UNSPECIFIED SITE OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES 203.00 - 203.02 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MULTIPLE MYELOMA, IN RELAPSE 203.10 - 203.12 PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - PLASMA CELL LEUKEMIA, IN RELAPSE 203.80 - 203.82 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 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Data Source: https://www.novitas-solutions.com Cytogenetic Analysis Testing (Page 3 of 7) CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88299, 88365, 88367, 88368 LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques, and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 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 205.00 - 205.92 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE 206.00 - 206.92 ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE 207.00 - 207.82 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, 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 223.3 BENIGN NEOPLASM OF BLADDER 225.2 BENIGN NEOPLASM OF CEREBRAL MENINGES 228.1 LYMPHANGIOMA ANY 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Data Source: https://www.novitas-solutions.com Cytogenetic Analysis Testing (Page 4 of 7) CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88299, 88365, 88367, 88368 LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques, and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 230.0 CARCINOMA IN SITU OF LIP ORAL CAVITY AND PHARYNX 231.0 CARCINOMA IN SITU OF LARYNX 232.9 CARCINOMA IN SITU OF SKIN SITE UNSPECIFIED 233.0 CARCINOMA IN SITU OF BREAST 233.30 - 233.39 CARCINOMA IN SITU, UNSPECIFIED FEMALE GENITAL ORGAN - CARCINOMA IN SITU, OTHER FEMALE GENITAL ORGAN 233.7 CARCINOMA IN SITU OF BLADDER 233.9 CARCINOMA IN SITU OF OTHER AND UNSPECIFIED URINARY ORGANS 234.0 CARCINOMA IN SITU OF EYE 236.7 NEOPLASM OF UNCERTAIN BEHAVIOR OF BLADDER 238.4 POLYCYTHEMIA VERA 238.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF HISTIOCYTIC AND MAST CELLS 238.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS 238.71 - 238.79 ESSENTIAL THROMBOCYTHEMIA - OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES 239.2 NEOPLASM OF UNSPECIFIED NATURE OF BONE SOFT TISSUE AND SKIN 239.3 NEOPLASM OF UNSPECIFIED NATURE OF BREAST 256.39 257.8 259.0 OTHER OVARIAN FAILURE OTHER TESTICULAR DYSFUNCTION DELAY IN SEXUAL DEVELOPMENT AND PUBERTY NOT ELSEWHERE CLASSIFIED 273.1 MONOCLONAL PARAPROTEINEMIA 273.3 MACROGLOBULINEMIA 279.11 DIGEORGE'S SYNDROME 284.01 - 284.9 CONSTITUTIONAL RED BLOOD CELL APLASIA APLASTIC ANEMIA UNSPECIFIED 285.0 SIDEROBLASTIC ANEMIA 285.1 ACUTE POSTHEMORRHAGIC ANEMIA 285.21 - 285.29 ANEMIA IN CHRONIC KIDNEY DISEASE - ANEMIA OF OTHER CHRONIC DISEASE 285.8 OTHER SPECIFIED ANEMIAS 285.9 ANEMIA UNSPECIFIED 287.30 - 287.39 PRIMARY THROMBOCYTOPENIA,UNSPECIFIED OTHER PRIMARY THROMBOCYTOPENIA 287.49 OTHER SECONDARY THROMBOCYTOPENIA 288.01* CONGENITAL NEUTROPENIA 288.02 CYCLIC NEUTROPENIA 288.09 OTHER NEUTROPENIA 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Data Source: https://www.novitas-solutions.com Cytogenetic Analysis Testing (Page 5 of 7) CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88299, 88365, 88367, 88368 LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques, and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 288.1 - 288.4 FUNCTIONAL DISORDERS OF POLYMORPHONUCLEAR NEUTROPHILS HEMOPHAGOCYTIC SYNDROMES 288.59 OTHER DECREASED WHITE BLOOD CELL COUNT 288.63 MONOCYTOSIS (SYMPTOMATIC) 288.64 PLASMACYTOSIS 288.65 BASOPHILIA 288.69 OTHER ELEVATED WHITE BLOOD CELL COUNT 288.8 OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS 289.6 FAMILIAL POLYCYTHEMIA 289.7 METHEMOGLOBINEMIA 289.81 - 289.83 PRIMARY HYPERCOAGULABLE STATE – MYELOFIBROSIS 289.89 OTHER SPECIFIED DISEASES OF BLOOD AND BLOOD-FORMING ORGANS 299.00 - 299.11 AUTISTIC DISORDER, CURRENT OR ACTIVE STATE CHILDHOOD DISINTEGRATIVE DISORDER, RESIDUAL STATE 317 - 319 MILD INTELLECTUAL DISABILITIES - UNSPECIFIED INTELLECTUAL DISABILITIES 334.8 OTHER SPINOCEREBELLAR DISEASES 388.5 DISORDERS OF ACOUSTIC NERVE 389.10 SENSORINEURAL HEARING LOSS UNSPECIFIED 599.70 - 599.72 HEMATURIA, UNSPECIFIED - MICROSCOPIC HEMATURIA 606.0 AZOOSPERMIA 606.1 OLIGOSPERMIA 611.1 HYPERTROPHY OF BREAST 628.9 INFERTILITY FEMALE OF UNSPECIFIED ORIGIN 629.9 UNSPECIFIED DISORDER OF FEMALE GENITAL ORGANS 630 HYDATIDIFORM MOLE 631.0 INAPPROPRIATE CHANGE IN QUANTITATIVE HUMAN CHORIONIC GONADOTROPIN (HCG) IN EARLY PREGNANCY 631.8 OTHER ABNORMAL PRODUCTS OF CONCEPTION 632 MISSED ABORTION 634.00 - 634.92 SPONTANEOUS ABORTION UNSPECIFIED COMPLICATED BY GENITAL TRACT AND PELVIC INFECTION - SPONTANEOUS ABORTION COMPLETE WITHOUT COMPLICATION 646.33 RECURRENT PREGNANCY LOSS, ANTEPARTUM CONDITION OR COMPLICATION 653.70 OTHER FETAL ABNORMALITY CAUSING DISPROPORTION UNSPECIFIED AS TO EPISODE OF CARE 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Data Source: https://www.novitas-solutions.com Cytogenetic Analysis Testing (Page 6 of 7) CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88299, 88365, 88367, 88368 LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques, and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 653.71 OTHER FETAL ABNORMALITY CAUSING DISPROPORTION DELIVERED 653.73 OTHER FETAL ABNORMALITY CAUSING DISPROPORTION ANTEPARTUM 655.00 - 655.23 CENTRAL NERVOUS SYSTEM MALFORMATION IN FETUS UNSPECIFIED AS TO EPISODE OF CARE IN PREGNANCY - HEREDITARY DISEASE IN FAMILY POSSIBLY AFFECTING FETUS AFFECTING MANAGEMENT OF MOTHER ANTEPARTUM CONDITION OR COMPLICATION 656.40 - 656.63 INTRAUTERINE DEATH AFFECTING MANAGEMENT OF MOTHER UNSPECIFIED AS TO EPISODE OF CARE - EXCESSIVE FETAL GROWTH AFFECTING MANAGEMENT OF MOTHER ANTEPARTUM 657.00 - 657.03 POLYHYDRAMNIOS UNSPECIFIED AS TO EPISODE OF CARE - POLYHYDRAMNIOS ANTEPARTUM COMPLICATION 658.00 - 658.03 OLIGOHYDRAMNIOS UNSPECIFIED AS TO EPISODE OF CARE - OLIGOHYDRAMNIOS ANTEPARTUM 659.50 - 659.53 ELDERLY PRIMIGRAVIDA UNSPECIFIED AS TO EPISODE OF CARE - ELDERLY PRIMIGRAVIDA ANTEPARTUM 659.60 - 659.63 OTHER ADVANCED MATERNAL AGE UNSPECIFIED AS TO EPISODE OF CARE OR NOT APPLICABLE - OTHER ADVANCED MATERNAL AGE ANTEPARTUM CONDITION OR COMPLICATION 740.0 - 759.9 ANENCEPHALUS - CONGENITAL ANOMALY UNSPECIFIED 764.90 - 764.99 FETAL GROWTH RETARDATION UNSPECIFIED WEIGHT - FETAL GROWTH RETARDATION 2500 GRAMS AND OVER 779.9 UNSPECIFIED CONDITION ORIGINATING IN THE PERINATAL PERIOD 783.22 UNDERWEIGHT 783.40 - 783.43 UNSPECIFIED LACK OF NORMAL PHYSIOLOGICAL DEVELOPMENT - SHORT STATURE 792.3 NONSPECIFIC ABNORMAL FINDINGS IN AMNIOTIC FLUID 796.5 ABNORMAL FINDING ON ANTENATAL SCREENING 796.6 NONSPECIFIC ABNORMAL FINDINGS ON NEONATAL SCREENING 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Data Source: https://www.novitas-solutions.com Cytogenetic Analysis Testing (Page 7 of 7) CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88299, 88365, 88367, 88368 LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques, and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 996.81 - 996.87 COMPLICATIONS OF TRANSPLANTED KIDNEY COMPLICATIONS OF TRANSPLANTED ORGAN INTESTINE 996.89 COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN V13.61 - V13.69 PERSONAL HISTORY OF (CORRECTED) HYPOSPADIAS - PERSONAL HISTORY OF OTHER (CORRECTED) CONGENITAL MALFORMATIONS V18.4 FAMILY HISTORY OF INTELLECTUAL DISABILITIES V19.5 FAMILY HISTORY OF CONGENITAL ANOMALIES V23.2 SUPERVISION OF HIGH-RISK PREGNANCY WITH HISTORY OF ABORTION V23.81 - V23.82 SUPERVISION OF HIGH-RISK PREGNANCY WITH ELDERLY PRIMIGRAVIDA - SUPERVISION OF HIGHRISK PREGNANCY WITH ELDERLY MULTIGRAVIDA V28.0 - V28.4 ANTENATAL SCREENING FOR CHROMOSOMAL ANOMALIES BY AMNIOCENTESIS - ANTENATAL SCREENING FOR FETAL GROWTH RETARDATION USING ULTRASONICS V49.89* OTHER SPECIFIED CONDITIONS INFLUENCING HEALTH STATUS *288.01 Limited to infantile genetic agranulocytosis only *V49.89 To be used only when repeat testing is believed to be medically reasonable and necessary, and must be listed as secondary with the primary neoplastic diagnosis. This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov. Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it. Source: Federal Registry Negotiated Rule-making, November 23, 2001 “The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.” Last Updated: Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Debridement of Mycotic Nails CPT Code: 87101, 87102, 87220 Data Source: https://www.novitas-solutions.com LCD Description: Fungal disease of the toenails is a comparatively benign condition, but difficult to eradicate due to a high recurrence rate. A superficial variety of fungal infections produce little or no symptomatology beyond white opacities on the nails. However, deep infections may result in dystrophic nails, with subsequent pain and/or limitation of ambulation, and/or secondary infection. The definitive treatment may involve a short-term use of oral agents, long term use of topical agents and/or periodic debridement of the dystrophic fungal nails with thinning of the nail plates (manual or electric). 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. Primary Diagnosis 110.1 DERMATOPHYTOSIS OF NAIL Secondary Diagnosis 681.10 681.11 703.0 719.7 729.5 781.2 UNSPECIFIED CELLULITIS AND ABSCESS OF TOE ONYCHIA AND PARONYCHIA OF TOE INGROWING NAIL DIFFICULTY IN WALKING PAIN IN LIMB ABNORMALITY OF GAIT *According to Higmark Medicare, ICD-9-CM code 110.1 must appear on each claim in addition to one of the other above ICD-9-CM codes that indicates secondary infection, pain, or difficulty in ambulation. 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Flow Cytometry (1 of 4) CPT Code: 88184, 88185, 88187, 88188, 88189 Data Source: https://www.novitas-solutions.com LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical analysis and interpretations are done by an experienced physician, usually a pathologist. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 200.80 - 200.88 042 079.51 - 079.53 197.2 197.6 200.00 - 200.08 200.10 - 200.18 200.20 - 200.28 200.30 - 200.38 200.40 - 200.48 200.50 - 200.58 200.60 - 200.68 200.70 - 200.78 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE I [HTLV-I] HUMAN IMMUNODEFICIENCY VIRUS TYPE 2 [HIV-2] SECONDARY MALIGNANT NEOPLASM OF PLEURA SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM RETICULOSARCOMA UNSPECIFIED SITE - RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES LYMPHOSARCOMA UNSPECIFIED SITE - LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 201.00 - 201.08 201.10 - 201.18 201.20 - 201.28 201.40 - 201.48 201.50 - 201.58 201.60 - 201.68 201.70 - 201.78 201.90 - 201.98 201.10 - 201.18 202.00 - 202.08 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S GRANULOMA UNSPECIFIED SITE - HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S SARCOMA UNSPECIFIED SITE - HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE - HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE - HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE - HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE - HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S GRANULOMA UNSPECIFIED SITE - HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Flow Cytometry (2 of 4) CPT Code: 88184, 88185, 88187, 88188, 88189 Data Source: https://www.novitas-solutions.com LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical analysis and interpretations are done by an experienced physician, usually a pathologist. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 203.80 - 203.82 202.20 - 202.28 202.30 - 202.38 202.40 - 202.48 202.50 - 202.58 202.60 - 202.68 202.70 - 202.78 202.80 - 202.88 202.90 - 202.98 203.00 203.02 203.10 - 203.12 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 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 204.00 - 204.02 204.10 - 204.12 204.20 - 204.22 204.80 - 204.82 204.90 - 204.92 205.00 - 205.02 205.10 - 205.12 205.20 - 205.22 205.30 - 205.32 205.80 - 205.82 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE LYMPHOID LEUKEMIA, IN RELAPSE CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER LYMPHOID LEUKEMIA, IN RELAPSE UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MYELOID LEUKEMIA, IN RELAPSE CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC MYELOID LEUKEMIA, IN RELAPSE SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE MYELOID LEUKEMIA, IN RELAPSE MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MYELOID SARCOMA, IN RELAPSE OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER MYELOID 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Flow Cytometry (3 of 4) CPT Code: 88184, 88185, 88187, 88188, 88189 Data Source: https://www.novitas-solutions.com LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical analysis and interpretations are done by an experienced physician, usually a pathologist. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 208.00 - 208.02 205.90 - 205.92 206.00 - 206.02 206.10 - 206.12 206.20 - 206.22 206.80 - 206.82 206.90 - 206.92 207.00 - 207.02 207.10 - 207.12 207.20 - 207.22 207.80 - 207.82 UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER MONOCYTIC LEUKEMIA, IN RELAPSE UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC ERYTHREMIA, IN RELAPSE MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MEGAKARYOCYTIC LEUKEMIA, IN RELAPSE OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER SPECIFIED LEUKEMIA, IN RELAPSE 208.10 - 208.12 208.20 - 208.22 208.80 - 208.82 208.90 - 208.92 238.71 - 238.77 238.79 273.1 - 273.3 273.8 - 273.9 279.00 - 279.06 279.09 279.10 - 279.13 279.19 279.2 - 279.3 279.41 279.49 ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION – CHRONICLEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED LEUKEMIA, IN RELAPSE ESSENTIAL THROMBOCYTHEMIA - POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD) OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES MONOCLONAL PARAPROTEINEMIA - MACROGLOBULINEMIA OTHER DISORDERS OF PLASMA PROTEIN METABOLISM UNSPECIFIED DISORDER OF PLASMA PROTEIN METABOLISM HYPOGAMMAGLOBULINEMIA UNSPECIFIED - COMMON VARIABLE IMMUNODEFICIENCY OTHER DEFICIENCY OF HUMORAL IMMUNITY IMMUNODEFICIENCY WITH PREDOMINANT T-CELL DEFECT UNSPECIFIED - NEZELOF'S SYNDROME OTHER DEFICIENCY OF CELL-MEDIATED IMMUNITY COMBINED IMMUNITY DEFICIENCY - UNSPECIFIED IMMUNITY DEFICIENCY AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME AUTOIMMUNE DISEASE, NOT ELSEWHERE CLASSIFIE 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Flow Cytometry (4 of 4) CPT Code: 88184, 88185, 88187, 88188, 88189 Data Source: https://www.novitas-solutions.com LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical analysis and interpretations are done by an experienced physician, usually a pathologist. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 288.8 - 288.9 OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS UNSPECIFIED DISEASE OF WHITE BLOOD CELLS OTHER SPECIFIED DISORDERS INVOLVING THE IMMUNE 289.4 HYPERSPLENISM MECHANISM - UNSPECIFIED DISORDER OF IMMUNE MECHANISM 289.50 - 289.53 DISEASE OF SPLEEN UNSPECIFIED – NEUTROPENIC 282.7 OTHER HEMOGLOBINOPATHIES 289.59 OTHER DISEASES OF SPLEEN 283.2 HEMOGLOBINURIA DUE TO HEMOLYSIS FROM EXTERNAL 289.83 MYELOFIBROSIS CAUSES 289.9 UNSPECIFIED DISEASES OF BLOOD AND BLOOD-FORMING 284.01 CONSTITUTIONAL RED BLOOD CELL APLASIA ORGANS 284.09 OTHER CONSTITUTIONAL APLASTIC ANEMIA 452 PORTAL VEIN THROMBOSIS 284.11 - 284.12 ANTINEOPLASTIC CHEMOTHERAPY INDUCED PANCYTOPENIA 453.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED SITE OTHER DRUG INDUCED PANCYTOPENIA 785.6 ENLARGEMENT OF LYMPH NODES 284.19 OTHER PANCYTOPENIA 789.2 SPLENOMEGALY 284.2 MYELOPHTHISIS 791.0 PROTEINURIA 284.81 RED CELL APLASIA (ACQUIRED) (ADULT) (WITH THYMOMA) 795.4 OTHER NONSPECIFIC ABNORMAL HISTOLOGICAL FINDINGS 284.89 OTHER SPECIFIED APLASTIC ANEMIAS 996.80 - 996.89 COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN 284.9 APLASTIC ANEMIA UNSPECIFIED COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN 285.0 SIDEROBLASTIC ANEMIA V08 ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV) 285.22 ANEMIA IN NEOPLASTIC DISEASE INFECTION STATUS 285.8 - 285.9 OTHER SPECIFIED ANEMIAS - ANEMIA UNSPECIFIED V10.60 - V10.63 PERSONAL HISTORY OF UNSPECIFIED LEUKEMIA 287.30 - 287.33 PRIMARY THROMBOCYTOPENIA,UNSPECIFIED - CONGENITAL PERSONAL HISTORY OF MONOCYTIC LEUKEMIA AND EREDITARY THROMBOCYTOPENIC PURPURA V10.69 PERSONAL HISTORY OF OTHER LEUKEMIA 287.39 OTHER PRIMARY THROMBOCYTOPENIA V10.91 PERSONAL HISTORY OF MALIGNANT NEUROENDOCRINE 287.5 THROMBOCYTOPENIA UNSPECIFIED TUMOR 288.00 - 288.04 NEUTROPENIA, UNSPECIFIED - NEUTROPENIA DUE TO V42.0 - V42.7 KIDNEY REPLACED BY TRANSPLANT - LIVER REPLACED BY INFECTION TRANSPLANT 288.09 OTHER NEUTROPENIA V42.81 - V42.84 BONE MARROW REPLACED BY TRANSPLANT - ORGAN OR 288.1 - 288.4 FUNCTIONAL DISORDERS OF POLYMORPHONUCLEAR TISSUE REPLACED BY TRANSPLANT INTESTINES NEUTROPHILS - HEMOPHAGOCYTIC SYNDROMES V42.89 OTHER SPECIFIED ORGAN OR TISSUE REPLACED BY 288.50 - 288.51 LEUKOCYTOPENIA, UNSPECIFIED – LYMPHOCYTOPENIA TRANSPLANT 288.59 OTHER DECREASED WHITE BLOOD CELL COUNT V42.9 UNSPECIFIED ORGAN OR TISSUE REPLACED BY TRANSPLANT 288.60 - 288.65 LEUKOCYTOSIS, UNSPECIFIED – BASOPHILIA SPLENOMEGALY 288.69 OTHER ELEVATED WHITE BLOOD CELL COUNT 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved 279.8 - 279.9 Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Flow Cytometry: Cell Cycle or DNA Analysis CPT Code: 88182 Data Source: https://www.novitas-solutions.com LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical analysis and interpretations are done by an experienced physician, usually a pathologist. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 150.0 - 150.5 150.8 - 150.9 151.0 - 151.6 151.8 - 151.9 153.0 - 153.9 154.0 154.1 174.0 - 174.6 174.8 - 174.9 175.0 175.9 183.0 183.8 185 188.0 188.1 - 188.9 193 194.0 198.81 227.0 233.0 259.2 MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION MALIGNANT NEOPLASM OF RECTUM MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST MALIGNANT NEOPLASM OF OVARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA MALIGNANT NEOPLASM OF PROSTATE MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER - MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED MALIGNANT NEOPLASM OF THYROID GLAND MALIGNANT NEOPLASM OF ADRENAL GLAND SECONDARY MALIGNANT NEOPLASM OF BREAST BENIGN NEOPLASM OF ADRENAL GLAND CARCINOMA IN SITU OF BREAST CARCINOID SYNDROME 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) ImmunoCAP(R) Radioallergosorbent Test, Fluoroallergosorbent Testing (1 of 2) CPT Code: 86003 Data Source: https://www.novitas-solutions.com LCD Description: ImmunoCAP(R) radioallergosorbent test, fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patients serum contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical examination of the patient. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 477.0 477.1 477.2 477.8 477.9 493.00 493.01 493.02 493.82 493.90 493.91 493.92 691.8 708.0 708.8 708.9 786.07 ALLERGIC RHINITIS DUE TO POLLEN ALLERGIC RHINITIS DUE TO FOOD ALLERGIC RHINITIS, DUE TO ANIMAL (CAT) (DOG) HAIR AND DANDER ALLERGIC RHINITIS DUE TO OTHER ALLERGEN ALLERGIC RHINITIS CAUSE UNSPECIFIED EXTRINSIC ASTHMA UNSPECIFIED EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION COUGH VARIANT ASTHMA ASTHMA UNSPECIFIED ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION OTHER ATOPIC DERMATITIS AND RELATED CONDITIONS ALLERGIC URTICARIA OTHER SPECIFIED URTICARIA UNSPECIFIED URTICARIA WHEEZING 989.5* 995.0 995.1 995.20 995.22 995.27 995.29 995.3 995.60 995.61 995.62 995.63 TOXIC EFFECT OF VENOM OTHER ANAPHYLACTIC SHOCK NOT ELSEWHERE CLASSIFIED ANGIONEUROTIC EDEMA NOT ELSEWHERE CLASSIFIED UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE UNSPECIFIED ADVERSE EFFECT OF ANESTHESIA OTHER DRUG ALLERGY UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE ALLERGY UNSPECIFIED NOT ELSEWHERE CLASSIFIED ANAPHYLACTIC SHOCK DUE TO UNSPECIFIED FOOD ANAPHYLACTIC SHOCK DUE TO PEANUTS ANAPHYLACTIC SHOCK DUE TO CRUSTACEANS ANAPHYLACTIC SHOCK DUE TO FRUITS AND VEGETABLES 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) ImmunoCAP(R) Radioallergosorbent Test, Fluoroallergosorbent Testing (2 of 2) Data Source: https://www.novitas-solutions.com CPT Code: 86003 LCD Description: ImmunoCAP(R) radioallergosorbent test, fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patients serum contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical examination of the patient. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 995.64 995.65 995.66 995.67 995.68 995.69 V15.09 ANAPHYLACTIC SHOCK DUE TO TREE NUTS AND SEEDS ANAPHYLACTIC SHOCK DUE TO FISH ANAPHYLACTIC SHOCK DUE TO FOOD ADDITIVES ANAPHYLACTIC SHOCK DUE TO MILK PRODUCTS ANAPHYLACTIC SHOCK DUE TO EGGS ANAPHYLACTIC SHOCK DUE TO OTHER SPECIFIED FOOD PERSONAL HISTORY OF OTHER ALLERGY OTHER THAN TO MEDICINAL AGENTS Utilization Guidelines CPT code 86003 will be covered for only thirty (30) units in a year. Services exceeding this parameter will be considered not medically necessary. Claims for RAST, FAST, ELISA, or multiple antigen simultaneous testing for specific IgE should be processed under CPT code 86003. Per Novitas Medicare the following tests are considered to be not medically necessary and will be denied: IgG ELISA, indirect method (CPT code 86001) Qualitative multi-allergen screen (CPT code 86005)-This is a non-specific test that does not identify a specific antigen. According to the Medicare Local Coverage Determination policy, IgG and IgG subclass antibody tests for food allergy do not have clinical relevance, are not validated, lack sufficient quality control, and should not be performed. *ICD-9-CM code 989.5 should be reported for venom hypersensitivity. 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Moh’s Micrographic Surgery (1 of 2) CPT Code: 88304, 88305, 88307, 88331, 88332, 88342 Data Source: https://www.novitas-solutions.com LCD Description: Moh’s Micrographic Surgery (MMS) is a microscopically controlled tissue-sparing surgical technique of removing complex or ill-defined cancerous tissues of the skin. The surgery is usually performed in an outpatient setting under local anesthesia, with or without sedation. MMS involves obtaining of tangential specimen of tumor with a minimal margin of clinically normal-appearing tissue, precisely mapped, and processed immediately by frozen section for microscopic examination. This process of removal of complex or ill-defined skin cancer requires a single physician to act in two integrated, but separate and distinct capacities: surgeon and pathologist, trained and highly skilled in MMS techniques and pathology identification. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 140.0 - 140.9 141.0 - 141.9 144.0 - 144.9 145.0 - 145.9 160.0 160.2 - 160.9 161.0 - 161.9 171.0 - 171.9 172.0 - 172.9 173.00 - 173.99 184.1 - 184.9 187.1 - 187.4 MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER MALIGNANT NEOPLASM OF BASE OF TONGUE - MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH - MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED MALIGNANT NEOPLASM OF CHEEK MUCOSA - MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED MALIGNANT NEOPLASM OF NASAL CAVITIES MALIGNANT NEOPLASM OF MAXILLARY SINUS - MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED MALIGNANT NEOPLASM OF GLOTTIS – MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK - MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED MALIGNANT MELANOMA OF SKIN OF LIP - MELANOMA OF SKIN SITE UNSPECIFIED UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP - OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED MALIGNANT NEOPLASM OF LABIA MAJORA - MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED MALIGNANT NEOPLASM OF PREPUCE - MALIGNANT NEOPLASM OF PENIS PART UNSPECIFIED 187.7 - 187.9 209.30 - 209.36 232.0 - 232.9 233.31 233.32 233.39 233.6 238.1 238.2 279.00 - 279.9 440.0 440.1 440.20 440.21 440.22 440.23 MALIGNANT NEOPLASM OF SCROTUM - MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE UNSPECIFIED MALIGNANT POORLY DIFFERENTIATED NEUROENDOCRINE CARCINOMA, ANY SITE - MERKEL CELL CARCINOMA OF OTHER SITES CARCINOMA IN SITU OF SKIN OF LIP - CARCINOMA IN SITU OF SKIN SITE UNSPECIFIED CARCINOMA IN SITU, VAGINA CARCINOMA IN SITU, VULVA CARCINOMA IN SITU, OTHER FEMALE GENITAL ORGAN CARCINOMA IN SITU OF OTHER AND UNSPECIFIED MALE GENITAL ORGANS NEOPLASM OF UNCERTAIN BEHAVIOR OF CONNECTIVE AND OTHER SOFT TISSUE NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN HYPOGAMMAGLOBULINEMIA UNSPECIFIED - UNSPECIFIED DISORDER OF IMMUNE MECHANISM ATHEROSCLEROSIS OF AORTA ATHEROSCLEROSIS OF RENAL ARTERY ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Moh’s Micrographic Surgery (2 of 2) CPT Code: 88304, 88305, 88307, 88331, 88332, 88342 Data Source: https://www.novitas-solutions.com LCD Description: Moh’s Micrographic Surgery (MMS) is a microscopically controlled tissue-sparing surgical technique of removing complex or ill-defined cancerous tissues of the skin. The surgery is usually performed in an outpatient setting under local anesthesia, with or without sedation. MMS involves obtaining of tangential specimen of tumor with a minimal margin of clinically normal-appearing tissue, precisely mapped, and processed immediately by frozen section for microscopic examination. This process of removal of complex or ill-defined skin cancer requires a single physician to act in two integrated, but separate and distinct capacities: surgeon and pathologist, trained and highly skilled in MMS techniques and pathology identification. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 440.24 440.29 440.30 440.31 440.32 440.4 440.8 440.9 443.1 443.81 443.82 443.89 443.9 444.22 444.81 451.0 451.11 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE OTHER ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE EXTREMITIES ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTREMITIES ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES CHRONIC TOTAL OCCLUSION OF ARTERY OF THE EXTREMITIES ATHEROSCLEROSIS OF OTHER SPECIFIED ARTERIES GENERALIZED AND UNSPECIFIED ATHEROSCLEROSIS THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE) PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE ERYTHROMELALGIA OTHER PERIPHERAL VASCULAR DISEASE PERIPHERAL VASCULAR DISEASE UNSPECIFIED ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY EMBOLISM AND THROMBOSIS OF ILIAC ARTERY PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) 451.19 451.2 454.0 - 454.9 457.0 457.1 459.10 - 459.19 459.2 459.81 459.89 692.82 757.0 782.3 940.0 - 940.5 PHLEBITIS AND THROMBOPHLEBITIS OF OTHER PHLEBITIS AND THROMBOPHLEBITIS OF LOWER EXTREMITIES UNSPECIFIED VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER ASYMPTOMATIC VARICOSE VEINS POSTMASTECTOMY LYMPHEDEMA SYNDROME OTHER LYMPHEDEMA POSTPHLEBETIC SYNDROME WITHOUT COMPLICATIONS POSTPHLEBETIC SYNDROME WITH OTHER COMPLICATION COMPRESSION OF VEIN VENOUS (PERIPHERAL) INSUFFICIENCY UNSPECIFIED OTHER SPECIFIED CIRCULATORY SYSTEM DISORDERS DERMATITIS DUE TO OTHER RADIATION HEREDITARY EDEMA OF LEGS EDEMA CHEMICAL BURN OF EYELIDS AND PERIOCULAR AREA BURN WITH RESULTING RUPTURE AND DESTRUCTION OF EYEBALL 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Molecular Diagnostics: Genitourinary Infectious Disease (1 of 3) CPT Code: 87480, 87490, 87491, 87510, 87590, 87591, 87660 Data Source: https://www.novitas-solutions.com LCD Description: Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, 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 limited coverage table below denotes infectious disease manifestations in the area of genitourinary (“GU”) testing for those organisms where specific CPT codes exist versus organisms which would require non-specific coding . 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 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 - 098.53 098.59 098.6 - 098.7 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 GONOCOCCAL INFECTION OF PHARYNX GONOCOCCAL INFECTION OF ANUS AND RECTUM 098.81 - 098.86 098.89 099.1 099.3 099.41 099.50 - 099.56 099.59 112.1 - 112.2 131.00 - 131.03 131.09 131.8 - 131.9 288.00 - 288.04 288.09 288.66 288.8 289.1 289.53 289.83 372.00 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 OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS OTHER SPECIFIED SITE CANDIDIASIS OF VULVA AND VAGINA - CANDIDIASIS OF OTHER UROGENITAL SITES UROGENITAL TRICHOMONIASIS UNSPECIFIED - TRICHOMONAL PROSTATITIS OTHER UROGENITAL TRICHOMONIASIS TRICHOMONIASIS OF OTHER SPECIFIED SITES TRICHOMONIASIS UNSPECIFIED NEUTROPENIA, UNSPECIFIED - NEUTROPENIA DUE TO INFECTION OTHER NEUTROPENIA BANDEMIA OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS CHRONIC LYMPHADENITIS NEUTROPENIC SPLENOMEGALY MYELOFIBROSIS ACUTE CONJUNCTIVITIS 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Molecular Diagnostics: Genitourinary Infectious Disease (2 of 3) CPT Code: 87480, 87490, 87491, 87510, 87590, 87591, 87660 Data Source: https://www.novitas-solutions.com LCD Description: Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, 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 limited coverage table below denotes infectious disease manifestations in the area of genitourinary (“GU”) testing for those organisms where specific CPT codes exist versus organisms which would require non-specific coding . 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 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 - 614.4 614.6 614.8 - 614.9 616.0 616.81 616.89 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 PROSTATEPROSTATITIS 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) OTHER SPECIFIED INFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS AND TISSUES - UNSPECIFIED INFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS AND TISSUES CERVICITIS AND ENDOCERVICITIS MUCOSITIS (ULCERATIVE) OF CERVIX, VAGINA, AND VULVA OTHER INFLAMMATORY DISEASE OF CERVIX, VAGINA AND VULVA 616.9 628.2 629.89 683 711.90 - 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 UNSPECIFIED INFLAMMATORY DISEASE OF CERVIX VAGINA AND VULVA INFERTILITY FEMALE OF TUBAL ORIGIN OTHER SPECIFIED DISORDERS OF FEMALE GENITAL ORGANS ACUTE LYMPHADENITIS 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 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Molecular Diagnostics: Genitourinary Infectious Disease (3 of 3) CPT Code: 87480, 87490, 87491, 87510, 87590, 87591, 87660 Data Source: https://www.novitas-solutions.com LCD Description: Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, 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 limited coverage table below denotes infectious disease manifestations in the area of genitourinary (“GU”) testing for those organisms where specific CPT codes exist versus organisms which would require non-specific coding . 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 788.64 - 788.65 788.7 789.00 - 789.07 789.09 789.1 - 789.2 789.30 - 789.37 789.39 789.40 - 789.47 RIGIDITY 789.49 789.51 789.59 789.60 - 789.67 789.69 789.9 790.4 - 790.5 790.7 791.0 - 791.7 791.9 URINARY HESITANCY - STRAINING ON URINATION URETHRAL DISCHARGE ABDOMINAL PAIN UNSPECIFIED SITE - ABDOMINAL PAIN GENERALIZED ABDOMINAL PAIN OTHER SPECIFIED SITE HEPATOMEGALY - SPLENOMEGALY ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED SITE - ABDOMINAL OR PELVIC SWELLING MASS OR LUMP GENERALIZED ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED SITE ABDOMINAL RIGIDITY UNSPECIFIED SITE - ABDOMINAL GENERALIZED ABDOMINAL RIGIDITY OTHER SPECIFIED SITE MALIGNANT ASCITES OTHER ASCITES ABDOMINAL TENDERNESS UNSPECIFIED SITE - ABDOMINAL TENDERNESS GENERALIZED ABDOMINAL TENDERNESS OTHER SPECIFIED SITE OTHER SYMPTOMS INVOLVING ABDOMEN AND PELVIS NONSPECIFIC ELEVATION OF LEVELS OF TRANSAMINASE OR LACTIC ACID DEHYDROGENASE (LDH) - OTHER NONSPECIFIC ABNORMAL SERUM ENZYME LEVELS BACTEREMIA PROTEINURIA - OTHER CELLS AND CASTS IN URINE OTHER NONSPECIFIC FINDINGS ON EXAMINATION OF URINE 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Molecular Diagnostics: Human Papillomavirus CPT Code: 87621 Data Source: https://www.novitas-solutions.com LCD Description: Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, 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 limited coverage table below denotes infectious disease manifestations in the area of genitourinary (“GU”) testing for those organisms where specific CPT codes exist versus organisms which would require non-specific coding . 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 622.10 - 622.12 795.00 - 795.01 CELLS OF 795.03 DYSPLASIA OF CERVIX, UNSPECIFIED - MODERATE DYSPLASIA OF CERVIX ABNORMAL GLANDULAR PAPANICOLAOU SMEAR OF CERVIX - PAPANICOLAOU SMEAR OF CERVIX WITH ATYPICAL SQUAMOUS UNDETERMINED SIGNIFICANCE (ASC-US) PAPANICOLAOU SMEAR OF CERVIX WITH LOW GRADE SQUAMOUS INTRAEPITHELIAL LESION (LGSIL) 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Molecular Diagnostics: Not otherwise specified CPT Code: 87798 Data Source: https://www.novitas-solutions.com LCD Description: Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, 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 limited coverage table below denotes infectious disease manifestations in the area of genitourinary (“GU”) testing for those organisms where specific CPT codes exist versus organisms which would require non-specific coding . 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 033.0 053.0 - 053.9 058.82 066.40 075 079.51 079.83 079.89 082.40 - 082.49 085.1 - 085.9 088.82 130.9 WHOOPING COUGH DUE TO BORDETELLA PERTUSSIS (B. PERTUSSIS) HERPES ZOSTER WITH MENINGITIS - HERPES ZOSTER WITHOUT COMPLICATION HUMAN HERPESVIRUS 7 INFECTION WEST NILE FEVER, UNSPECIFIED INFECTIOUS MONONUCLEOSIS HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE I [HTLV-I] PARVOVIRUSB19 OTHER SPECIFIED VIRAL INFECTION UNSPECIFIED EHRLICHIOSIS - OTHER EHRLICHIOSIS CUTANEOUS LEISHMANIASIS URBAN - LEISHMANIASIS UNSPECIFIED BABESIOSIS TOXOPLASMOSIS 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. 11/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) OVA-1 Assay Data Source: https://www.novitas-solutions.com CPT Code: 84999 LCD Description: The OVA-1 test is specifically indicated for the pre-surgical evaluation of women with an ovarian mass, and suspicion of an ovarian neoplasm. It uses the results of 5 known biomarkers (B-2 microglobulin, apolipoprotein A1, CA 125, transferrin, and transthyretin (prealbumin) to generate a numerical score that correlates with the likelihood of malignancy. It is not a screening study, and should not be used in women with a diagnosis of malignancy in the past five years. It should also not be used in women under age 18, or with a rheumatoid factor concentration of greater than or equal to 250 IU/ml. It is expected that the use of this test will be followed in a timely fashion by an appropriate diagnostic study to confirm a pathologic diagnosis. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 789.33 - 789.34 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP RIGHT LOWER QUADRANT ABDOMINAL OR PELVIC SWELLING MASS OR LUMP LEFT LOWER QUADRANT Utilization Guidelines It is expected that this study will be ordered once prior to the appropriate diagnostic study with appropriate pathologic diagnosis recorded as above. 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) PARATHORMONE (PARATHYROID HORMONE) CPT Code: 83970 Data Source: https://www.novitas-solutions.com LCD Description: Parathyroid hormone (PTH), a polypeptide hormone produced in the parathyroid gland, along with Vitamin D, is the principal regulator of calcium and phosphorus homeostasis. The most important actions of PTH are (1) rapid mobilization of calcium and phosphate from bone and long-term acceleration of bone resorption, (2) increasing renal tubular reabsorption of calcium, (3) increasing intestinal absorption of calcium (mediated by an action on the metabolism of vitamin D), and (4) decreasing renal tubular reabsorption of phosphate. These actions account for most of the important clinical manifestations of PTH excess or deficiency. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 227.1 BENIGN NEOPLASM OF PARATHYROID GLAND 252.00 - 252.9 HYPERPARATHYROIDISM, UNSPECIFIED UNSPECIFIED DISORDER OF PARATHYROID GLAND 268.0 - 268.9 RICKETS ACTIVE - UNSPECIFIED VITAMIN D DEFICIENCY 269.2 UNSPECIFIED VITAMIN DEFICIENCY 275.2 DISORDERS OF MAGNESIUM METABOLISM 275.3 DISORDERS OF PHOSPHORUS METABOLISM 275.40 - 275.49 UNSPECIFIED DISORDER OF CALCIUM METABOLISM - OTHER DISORDERS OF CALCIUM METABOLISM 278.4 HYPERVITAMINOSIS D 579.0 CELIAC DISEASE 585.1 - 585.9 CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED 586 RENAL FAILURE UNSPECIFIED 588.0 RENAL OSTEODYSTROPHY 588.81 SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) 592.0 - 592.9 CALCULUS OF KIDNEY - URINARY CALCULUS UNSPECIFIED 731.0 OSTEITIS DEFORMANS WITHOUT BONE TUMOR 733.00 – 733.09OSTEOPOROSIS UNSPECIFIED - OTHER OSTEOPOROSIS 733.29 733.90 733.91 733.93 733.95 733.99 781.7 791.9* V58.44 V67.00* V77.99* OTHER BONE CYST DISORDER OF BONE AND CARTILAGE UNSPECIFIED ARREST OF BONE DEVELOPMENT OR GROWTH STRESS FRACTURE OF TIBIA OR FIBULA STRESS FRACTURE OF OTHER BONE OTHER DISORDERS OF BONE AND CARTILAGE TETANY OTHER NONSPECIFIC FINDINGS ON EXAMINATION OF URINE AFTERCARE FOLLOWING ORGAN TRANSPLANT FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY SCREENING FOR OTHER AND UNSPECIFIED ENDOCRINE NUTRITIONAL METABOLIC AND IMMUNITY DISORDERS Note: per Novitas Medicare LCD policy ICD-9-CM code 791.9 should be used for patients with hypercalciuria. ICD-9-CM code V77.99 should be used for parathormone measurements performed during parathyroidectomy in the operating room. ICD-9-CM code V67.00 may be used for medically necessary parathormone measurements in the post operative period. 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Qualitative Drug Testing (Page 1 of 2) Data Source: https://www.highmarkmedicareservices.com CPT Code: 80102, G0431, G0434 LCD Description: A qualitative drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. However, urine is the best specimen for broad qualitative screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 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 427.0 427.1 780.01 780.09 780.1 780.39 780.97 963.0 965.00 965.01 965.02 965.09 965.1 965.4 965.5 965.61 966.1 967.0 967.1 967.2 967.3 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 POISONING BY CHLORAL HYDRATE GROUP POISONING BY PARALDEHYDE POISONING BY BROMINE COMPOUNDS 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. 5/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Qualitative Drug Testing (Page 2 of 2) Data Source: https://www.highmarkmedicareservices.com CPT Code: 80102, G0431, G0434 LCD Description: A qualitative drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. However, urine is the best specimen for broad qualitative screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 967.4 967.5 967.6 967.8 967.9 969.00 969.01 969.02 969.03 969.04 969.05 969.09 969.1 969.2 969.3 969.4 969.5 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 POISONING BY OTHER ANTIPSYCHOTICS NEUROLEPTICS AND MAJOR TRANQUILIZERS POISONING BY BENZODIAZEPINE-BASED TRANQUILIZERS POISONING BY OTHER TRANQUILIZERS 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 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. 5/15/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Vitamin D: 25 Hydroxy Data Source: https://www.novitas-solutions.com CPT Code: 82306 LCD Description: The most common type of vitamin D deficiency is that of 25 OH vitamin D. It is expected that the medical record will justify the tests chosen for a particular disease entity, that all available components of 25 OH vitamin D and other metabolite levels will not be performed routinely on every patient and that supportive documentation for test choices will be available. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 010.00 - 018.96 PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - UNSPECIFIED MILIARY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) 135 SARCOIDOSIS 252.02 SECONDARY HYPERPARATHYROIDISM, NON-RENAL 268.0 RICKETS ACTIVE 268.2 OSTEOMALACIA UNSPECIFIED 268.9 UNSPECIFIED VITAMIN D DEFICIENCY 275.3 DISORDERS OF PHOSPHORUS METABOLISM 275.41 HYPOCALCEMIA 275.42 HYPERCALCEMIA 278.8 OTHER HYPERALIMENTATION 359.5 MYOPATHY IN ENDOCRINE DISEASES CLASSIFIED ELSEWHERE 555.0 - 555.9 REGIONAL ENTERITIS OF SMALL INTESTINE REGIONAL ENTERITIS OF UNSPECIFIED SITE 556.0 - 556.9 ULCERATIVE (CHRONIC) ENTEROCOLITIS ULCERATIVE COLITIS UNSPECIFIED 571.2 ALCOHOLIC CIRRHOSIS OF LIVER 571.5 CIRRHOSIS OF LIVER WITHOUT ALCOHOL 571.6 BILIARY CIRRHOSIS 576.8 OTHER SPECIFIED DISORDERS OF BILIARY TRACT 579.0 - 579.9 CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION 585.3 585.4 585.5 585.6 696.1 710.0 710.3 729.1 733.00 - 733.09 733.90 756.51 756.52 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE OTHER PSORIASIS AND SIMILAR DISORDERS SYSTEMIC LUPUS ERYTHEMATOSUS DERMATOMYOSITIS MYALGIA AND MYOSITIS UNSPECIFIED OSTEOPOROSIS UNSPECIFIED – OTHER OSTEOPOROSIS DISORDER OF BONE AND CARTILAGE UNSPECIFIED OSTEOGENESIS IMPERFECTA OSTEOPETROSIS According to Novitas Medicare, use V58.65 with 268.2 to describe the current long term use of glucocorticoids and V58.69 with 268.2 describe long term use of anticonvulsants and other medication known to lower Vitamin D levels. Utilization Guidelines Only one 25 OH vitamin D level will be reimbursed in any 24 hour period. Assays of vitamin D levels for conditions other than ICD 9-CM codes 268.0268.9 will be limited to once a year. Assays of the appropriate vitamin D levels for ICD-9 CM codes 268.0-268.9 will be limited to 4 per year, for the previously identified deficient form of vitamin D. 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Vitamin D: 1,25 Dihydroxy CPT Code: 82652 Data Source: https://www.novitas-solutions.com LCD Description: The most common type of vitamin D deficiency is that of 25 OH vitamin D. A much smaller percentage of 1, 25 dihydroxy vitamin D deficiency exists; mostly in those with renal disease. It is expected that the medical record will justify the tests chosen for a particular disease entity, that all available components of 25 OH vitamin D and other metabolite levels will not be performed routinely on every patient and that supportive documentation for test choices will be available to the Contractor upon request. 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. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 010.00 - 018.96 PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - UNSPECIFIED MILIARY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) 135 SARCOIDOSIS 268.0 RICKETS ACTIVE 278.8 OTHER HYPERALIMENTATION 585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) 585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) 585.5 CHRONIC KIDNEY DISEASE, STAGE V 585.6 END STAGE RENAL DISEASE 756.51 OSTEOGENESIS IMPERFECTA 756.52 OSTEOPETROSIS According to Novitas Medicare, use V58.65 with 268.2 to describe the current long term use of glucocorticoids and V58.69 with 268.2 describe long term use of anticonvulsants and other medication known to lower Vitamin D levels. Utilization Guidelines Only one 1,25-OH vitamin D level will be reimbursed in a 24 hour period if medically necessary. Assays of vitamin D levels for conditions other than ICD 9-CM codes 268.0-268.9 will be limited to once a year. Assays of the appropriate vitamin D levels for ICD-9 CM codes 268.0-268.9 will be limited to 4 per year, for the previously identified deficient form of vitamin D. 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. 04/05/12 All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
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