Medicare National and Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
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 4/01/2012
• Click here for National MLCP Policies Tool
Document contains information on National Medicare
Limited Coverage Policies
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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
CT, MA, ME, NH, RI, VT
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B-type Natriuretic Peptide (BNP) Testing
Circulating Tumor Cell (CTC) Assay
Combined Ovarian Cancer Biomarker Tests
Galectin-3
Molecular Pathology Procedures
Qualitative Drug Screening
RAST Type Tests
Vitamin D Assay Testing
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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:
3/01/14
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Data Source: Local Coverage Determination for
B-type Natriuretic Peptide (BNP) Testing (1 of 2)
B-type Natriuretic Peptide (BNP) Testing (L26375)
CPT Code: 83880
LCD Description: B-type natriuretic peptide (BNP) is a cardiac neurohormone produced mainly in the left ventricle. It is secreted in response to ventricular volume
expansion and pressure overload, factors often found in congestive heart failure (CHF). Used in conjunction with other clinical information, rapid measurement of BNP
is useful in establishing or excluding the diagnosis and assessing the severity of CHF in patients with acute dyspnea so that appropriate and timely treatment can be
initiated.
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.
Table 1: ICD-9-CM codes that support medical necessity when billed in
either an office or outpatient setting.
Group 1 Codes:
402.01 MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART
FAILURE
402.11 BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE
402.91 UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART
FAILURE
404.01 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE,
MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY
DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED
404.03 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE,
MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY
DISEASE STAGE V OR END STAGE RENAL DISEASE
404.11 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN,
WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE
STAGE I THROUGH STAGE IV, OR UNSPECIFIED
404.13 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN,
WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V
OR END STAGE RENAL DISEASE
404.91 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE,
UNSPECIFIED, WITH HEART FAILURE AND WITH CHRONIC KIDNEY
DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED
404.93 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE,
UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY
DISEASE STAGE V OR END STAGE RENAL DISEASE
428.0 CONGESTIVE HEART FAILURE UNSPECIFIED
428.1 LEFT HEART FAILURE
428.20 UNSPECIFIED SYSTOLIC HEART FAILURE
428.21 ACUTE SYSTOLIC HEART FAILURE
428.22 CHRONIC SYSTOLIC HEART FAILURE
428.23 ACUTE ON CHRONIC SYSTOLIC HEART FAILURE
428.30 UNSPECIFIED DIASTOLIC HEART FAILURE
428.31 ACUTE DIASTOLIC HEART FAILURE
428.32 CHRONIC DIASTOLIC HEART FAILURE
428.33 ACUTE ON CHRONIC DIASTOLIC HEART FAILURE
428.40 UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART
FAILURE
428.41 ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE
428.42 CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE
428.43 ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART
FAILURE
428.9 HEART FAILURE UNSPECIFIED
491.21 OBSTRUCTIVE CHRONIC BRONCHITIS WITH (ACUTE)
EXACERBATION
491.22 OBSTRUCTIVE CHRONIC BRONCHITIS WITH ACUTE BRONCHITIS
493.22 CHRONIC OBSTRUCTIVE ASTHMA WITH (ACUTE) EXACERBATION
493.92 ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION
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.
4/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
B-type Natriuretic Peptide (BNP) Testing (2 of 2)
Data Source: Local Coverage Determination for
CPT Code: 83880
B-type Natriuretic Peptide (BNP) Testing (L26375)
LCD Description: B-type natriuretic peptide (BNP) is a cardiac neurohormone produced mainly in the left ventricle. It is secreted in response to ventricular volume
expansion and pressure overload, factors often found in congestive heart failure (CHF). Used in conjunction with other clinical information, rapid measurement of BNP
is useful in establishing or excluding the diagnosis and assessing the severity of CHF in patients with acute dyspnea so that appropriate and timely treatment can be
initiated
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.
519.11 ACUTE BRONCHOSPASM
786.00 RESPIRATORY ABNORMALITY UNSPECIFIED
786.02 ORTHOPNEA
786.05 SHORTNESS OF BREATH
786.06 TACHYPNEA
786.07 WHEEZING
786.09 RESPIRATORY ABNORMALITY OTHER
Utilization Guidelines:
The use of BNP for monitoring CHF is not covered.
Limitations:
BNP measurements must be analyzed in conjunction with standard diagnostic tests, medical history and clinical findings. The efficacy of BNP measurement as
a stand-alone test has not yet been established. Clinicians should be aware that certain conditions such as ischemia, infarction and renal insufficiency, may
cause elevation of circulating BNP concentration and require alterations of the interpretation of BNP results.
Additional investigation is required to further define the diagnostic value of plasma BNP in monitoring the efficiency of treatment for CHF and in tailoring the
therapy for heart failure. Therefore, BNP measurements for monitoring and management of CHF are not a covered service.
Although a correlation between serum BNP levels and the clinical severity of HF has been shown in broad populations, “it cannot be assumed that BNP levels
can be used effectively as targets for adjustment of therapy in individual patients. [T]he BNP measurement has not been clearly shown to supplement careful
clinical assessment.” (Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in
the Adult: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, pgs. 14-15)
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.
4/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Circulating Tumor Cell (CTC) Assay
Data Source: Local Coverage Determination for
CPT Code: 86152, 86153
Circulating Tumor Cell (CTC) Assay (L32965)
LCD Description: CTCs represent the point in the metastatic process of solid tumors when cells from a primary tumor invade, detach, disseminate, colonize and
proliferate in a distant site. Detection of elevated CTCs during therapy may be an accurate indication of subsequent rapid disease progression and mortality in breast,
colorectal and prostate cancer, noting that FDA labeling includes each of these neoplasms . Although some comparative cohort designs have been conducted to
express the clinical utility of such testing, the vast majority of studies have been uncontrolled one-arm studies
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.
Effective for dates of service on or after January 01, 2013, CTC should be reported using CPT codes 86152 and 86153.
86152 CELL ENUMERATION USING IMMUNOLOGIC SELECTION AND IDENTIFICATION IN FLUID SPECIMEN (EG, CIRCULATING TUMOR CELLS IN
BLOOD);
86153 CELL ENUMERATION USING IMMUNOLOGIC SELECTION AND IDENTIFICATION IN FLUID SPECIMEN (EG, CIRCULATING TUMOR CELLS IN
BLOOD); PHYSICIAN INTERPRETATION AND REPORT, WHEN REQUIRED
ICD-9 Codes that Support Medical Necessity
It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code
listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this
determination.
XX000 Not Applicable
Diagnoses that Support Medical Necessity
Not applicable
ICD-9 Codes that DO NOT Support Medical Necessity
Not applicable
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Not applicable
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.
1/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Combined Ovarian Cancer Biomarker Tests
Data Source: Local Coverage Determination for
CPT Code: 84999
Combined Ovarian Cancer Biomarker Tests
(L32589)
LCD Description: OVA-1 is an ovarian cancer blood test that is reported to detect ovarian cancer in a pelvic mass. It is an aggregation of five biomarkers, beta 2microglobulin, apolipoprotein A-1, CA-125, transferrin and transthyretin. The Risk of Ovarian Malignancy Algorithm (ROMA™), is another test which combines the
same traditionally proven tumor marker, CA-125, with HE-4, human epidydimus protein 4, a relatively new protein marker produced by the over-expression of the gene
WFDC2, and associated with epithelial ovarian neoplasia
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.
CPT/HCPCS Codes
84999 UNLISTED CHEMISTRY PROCEDURE
ICD-9 Codes that Support Medical Necessity
It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code
listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this
determination.
XX000 Not Applicable
Diagnoses that Support Medical Necessity
Not applicable
ICD-9 Codes that DO NOT Support Medical Necessity
Not applicable
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Not applicable
Indications and Limitations:
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
At the present time, National Government Services does not find either the OVA-1 or the ROMA ™ test to be of proven efficacy in the diagnosis or treatment of
ovarian cancer. National Government Services will only allow coverage of CA-125 as allowed by the national coverage decision.
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.
11/01/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Data Source: Local Coverage Determination for
Galectin-3
CPT Code: 82777
Galectin-3 (L32977)Part B - Medical Policy
Center
LCD Description: Galectin-3 is a circulating protein associated with the inflammatory response. Administration of exogenous galectin-3 in animal models is associated
with an accelerated rate of cardiac fibrosis. In a presentation given in the Netherlands, the review of galectin-3 levels obtained from over 8000 patients suggested they
were” a strong independent predictor of demise or early hospitalization.” The manufacturer has also filed for the expanded indication of a biomarker to identify those
patients with diabetes, hypertension, previous myocardial infarction and family members with congestive heart failure who are at increased risk of developing
congestive heart failure (CHF). Potential correlation with accelerated renal disease and eclampsia/pre-eclampsia is also reported to be under investigation.
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.
Effective for dates of service on or after 01/01/2013, CPT code 82777 should be used to report Galectin-3.
ICD-9 Codes that Support Medical Necessity
It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g., to the fourth or fifth digit). The correct use of an ICD-9-CM code
listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this
determination.
XX000 Not Applicable
Diagnoses that Support Medical Necessity
Not applicable
ICD-9 Codes that DO NOT Support Medical Necessity
Not applicable
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
Not applicable
Indications and Limitations:
Review of the literature suggests that at some point this assay may be found useful in the management of congestive heart failure. Presently, National Government
Services considers this assay for CHF patients and similar assays related to the elaboration of galectin-3 protein to be of an uncertain role in the clinical
management of patients. Consequently, it is considered not covered for all indications.
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.
2/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures
Data Source: Local Coverage Determination (LCD):
Pages 1 of 2
Molecular Pathology Procedures (L34506)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical
laboratory procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic
(e.g., neoplasia) conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array
based evaluation codes (88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization,
extraction, digestion, amplification, and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and
Laboratory section of CPT. For microbial identification using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in
situ hybridization analyses, CPT codes 88271-88275 and 88365-88368 apply.)
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.
CPT Codes:
81200
81201
81202
81203
81205
81206
81207
81208
81209
81210
81211
81212
81213
81214
81215
81217
81220
81221
81222
81223
81224
81225
81226
81227
81228
81229
81235
81240
81241
81242
81243
81244
81245
81250
81251
81252
81253
81254
81255
81256
81257
81260
81261
81262
81263
81264
81265
81266
81267
81268
81270
81275
81280
81281
81282
81287
81290
81291
81292
81293
81294
81295
81296
81297
81298
81299
81300
81301
81302
81303
81304
81310
81315
81316
81317
81318
81319
81321
81322
81323
81324
81325
81326
81330
81331
81332
81340
81341
81342
81350
81355
81400
81401
81402
81403
81404
81405
81406
81407
81408
81479
ICD-9 Codes that DO NOT Support Medical Necessity
N/A
Limitations:
• Any procedures required prior to cell lysis (e.g., microdissection [CPT codes 88380 and 88381]) should be reported separately and utilization must be clearly supported based on the application and clinical utility. Such claims may be subject to prepayment medical review. • HCPCS code G0452 with modifier 26 should be used by pathologists when an interpretation of a molecular pathology test is performed. Non physician practitioners (e.g., PhD, scientists etc.) are not eligible to report this code, only physicians may use/bill this code. This code should not be billed without modifier 26 since it is an interpretation code only.
• Testing for quality assurance (component of the service is not separately billable per CMS National Correct Coding Initiative (NCCI).
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.
3/01/14
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures
Data Source: Local Coverage Determination for
Pages 2 of 2
Molecular Pathology Procedures (L34506)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical
laboratory procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic
(e.g., neoplasia) conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array
based evaluation codes (88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization,
extraction, digestion, amplification, and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and
Laboratory section of CPT. For microbial identification using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in
situ hybridization analyses, CPT codes 88271-88275 and 88365-88368 apply.)
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.
Utilization Guidelines
Screening services such as pre-symptomatic genetic tests and services used to detect an undiagnosed disease or disease predisposition are not a
Medicare benefit and are not covered. Similarly, Medicare may not reimburse the costs of tests/examinations that assess the risk of a condition
unless the risk assessment clearly and directly effects the management of the patient.
Title XVIII of the Social Security Act (SSA) §1862(a)(1)(A) states that no Medicare payment shall be made for items and services which are not
reasonable and necessary for the diagnosis or treatment of illness or injury. Based on this statute, CMS states that “tests that are performed in the
absence of signs, symptoms, complaints, or personal history of disease or injury are non-covered unless explicitly authorized by statute.”
A specific genetic test may only be performed once in a lifetime per beneficiary for inherited conditions; however, when medically reasonable and
necessary, genetic testing may be done on acquired conditions such as malignancies (including separate malignancies developing at different
times) as they are treated and are being followed, in order to assess response or other relevant clinical criteria. Likewise, there are situations where
medical record and literature documentation are able to demonstrate that serial testing can be reasonably predicted to provide additional clinically
useful information. When the record documents that this information, such as confirmed significant response to current therapy, is likely to assist in
modifying treatment, serial testing can be considered reasonable and necessary and eligible for coverage.
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.
3/01/14
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
L28145 Qualitative Drug Screen (1 of 4)
CPT Codes: 80102, G0431, G0434
Data Source: Local Coverage Determination for
Qualitative Drug Screening (L28145)Part B - Medical
Policy Center
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.
For monitoring of patient compliance in a drug treatment program, use ICD-9-CM code V71.09 as the primary diagnosis and the specific drug dependence diagnosis
as the secondary diagnosis.
For the monitoring of patients on methadone maintenance and chronic pain patients with opioid dependence, suspected of abusing other illicit drugs, use code V58.69
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 ACIDOSIS
304.00 OPIOID TYPE DEPENDENCE UNSPECIFIED USE
304.01 OPIOID TYPE DEPENDENCE CONTINUOUS USE
304.02 OPIOID TYPE DEPENDENCE EPISODIC USE
304.03 OPIOID TYPE DEPENDENCE IN REMISSION
304.10 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE,
UNSPECIFIED
304.11 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE,
CONTINUOUS
304.12 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, EPISODIC
304.13 SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, IN
REMISSION
304.20 COCAINE DEPENDENCE UNSPECIFIED USE
304.21 COCAINE DEPENDENCE CONTINUOUS USE
304.22 COCAINE DEPENDENCE EPISODIC USE
304.23 COCAINE DEPENDENCE IN REMISSION
304.30 CANNABIS DEPENDENCE UNSPECIFIED USE
304.31 CANNABIS DEPENDENCE CONTINUOUS USE
304.32 CANNABIS DEPENDENCE EPISODIC USE
304.33 CANNABIS DEPENDENCE IN REMISSION
304.40 AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE
UNSPECIFIED USE
304.41 AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE
CONTINUOUS USE
304.42 AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE
EPISODIC USE
304.43 AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE
IN REMISSION
304.50 HALLUCINOGEN DEPENDENCE UNSPECIFIED USE
304.51 HALLUCINOGEN DEPENDENCE CONTINUOUS USE
304.52 HALLUCINOGEN DEPENDENCE EPISODIC USE
304.53 HALLUCINOGEN DEPENDENCE IN REMISSION
304.60 OTHER SPECIFIED DRUG DEPENDENCE UNSPECIFIED USE
304.61 OTHER SPECIFIED DRUG DEPENDENCE CONTINUOUS USE
304.62 OTHER SPECIFIED DRUG DEPENDENCE EPISODIC USE
304.63 OTHER SPECIFIED DRUG DEPENDENCE IN REMISSION
304.70 COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG
DEPENDENCE UNSPECIFIED USE
304.71 COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG
DEPENDENCE CONTINUOUS USE
304.72 COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG
DEPENDENCE EPISODIC USE
304.73 COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG
DEPENDENCE IN REMISSION
304.80 COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID
TYPE DRUG UNSPECIFIED USE
304.81 COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID
TYPE DRUG CONTINUOUS USE
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.
2/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
L28145 Qualitative Drug Screen (2 of 4)
Data Source: Local Coverage Determination for
CPT Codes: 80102, G0431, G0434
Qualitative Drug Screening (L28145)
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.
For monitoring of patient compliance in a drug treatment program, use ICD-9-CM code V71.09 as the primary diagnosis and the specific drug dependence diagnosis
as the secondary diagnosis.
For the monitoring of patients on methadone maintenance and chronic pain patients with opioid dependence, suspected of abusing other illicit drugs, use code V58.69
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.
304.82 COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID
TYPE DRUG EPISODIC USE
304.83 COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID
TYPE DRUG IN REMISSION
304.90 UNSPECIFIED DRUG DEPENDENCE UNSPECIFIED USE
304.91 UNSPECIFIED DRUG DEPENDENCE CONTINUOUS USE
304.92 UNSPECIFIED DRUG DEPENDENCE EPISODIC USE
304.93 UNSPECIFIED DRUG DEPENDENCE IN REMISSION
305.00 NONDEPENDENT ALCOHOL ABUSE UNSPECIFIED DRINKING
BEHAVIOR
305.01 NONDEPENDENT ALCOHOL ABUSE CONTINUOUS DRINKING
BEHAVIOR
305.02 NONDEPENDENT ALCOHOL ABUSE EPISODIC DRINKING
BEHAVIOR
305.03 NONDEPENDENT ALCOHOL ABUSE IN REMISSION
305.20 NONDEPENDENT CANNABIS ABUSE UNSPECIFIED USE
305.21 NONDEPENDENT CANNABIS ABUSE CONTINUOUS USE
305.22 NONDEPENDENT CANNABIS ABUSE EPISODIC USE
305.23 NONDEPENDENT CANNABIS ABUSE IN REMISSION
305.30 NONDEPENDENT HALLUCINOGEN ABUSE UNSPECIFIED USE
305.31 NONDEPENDENT HALLUCINOGEN ABUSE CONTINUOUS USE
305.32 NONDEPENDENT HALLUCINOGEN ABUSE EPISODIC USE
305.33 NONDEPENDENT HALLUCINOGEN ABUSE IN REMISSION
305.40 SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNSPECIFIED
305.41
305.42
305.43
305.50
305.51
305.52
305.53
305.60
305.61
305.62
305.63
305.70
305.71
305.72
305.73
305.80
305.81
305.82
SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, CONTINUOUS
SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, EPISODIC
SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, IN REMISSION
NONDEPENDENT OPIOID ABUSE UNSPECIFIED USE
NONDEPENDENT OPIOID ABUSE CONTINUOUS USE
NONDEPENDENT OPIOID ABUSE EPISODIC USE
NONDEPENDENT OPIOID ABUSE IN REMISSION
NONDEPENDENT COCAINE ABUSE UNSPECIFIED USE
NONDEPENDENT COCAINE ABUSE CONTINUOUS USE
NONDEPENDENT COCAINE ABUSE EPISODIC USE
NONDEPENDENT COCAINE ABUSE IN REMISSION
NONDEPENDENT AMPHETAMINE OR RELATED ACTING
SYMPATHOMIMETIC ABUSE UNSPECIFIED USE
NONDEPENDENT AMPHETAMINE OR RELATED ACTING
SYMPATHOMIMETIC ABUSE CONTINUOUS USE
NONDEPENDENT AMPHETAMINE OR RELATED ACTING
SYMPATHOMIMETIC ABUSE EPISODIC USE
NONDEPENDENT AMPHETAMINE OR RELATED ACTING
SYMPATHOMIMETIC ABUSE IN REMISSION
NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE UNSPECIFIED
USE
NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE CONTINUOUS
USE
NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE EPISODIC USE
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.
2/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
L28145 Qualitative Drug Screen (3 of 4)
Data Source: Local Coverage Determination for
CPT Codes: 80102, G0431, G0434
Qualitative Drug Screening (L28145)
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.
For monitoring of patient compliance in a drug treatment program, use ICD-9-CM code V71.09 as the primary diagnosis and the specific drug dependence diagnosis
as the secondary diagnosis.
For the monitoring of patients on methadone maintenance and chronic pain patients with opioid dependence, suspected of abusing other illicit drugs, use code V58.69
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.
305.83 NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE IN REMISSION
305.90 OTHER MIXED OR UNSPECIFIED DRUG ABUSE UNSPECIFIED
USE
305.91 NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE
CONTINUOUS USE
305.92 NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE
EPISODIC USE
305.93 NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE
IN REMISSION
345.10 GENERALIZED CONVULSIVE EPILEPSY WITHOUT INTRACTABLE
EPILEPSY
345.11 GENERALIZED CONVULSIVE EPILEPSY WITH INTRACTABLE
EPILEPSY
345.3 GRAND MAL STATUS EPILEPTIC
345.90 EPILEPSY UNSPECIFIED WITHOUT INTRACTABLE EPILEPSY
345.91 EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY
426.10 ATRIOVENTRICULAR BLOCK UNSPECIFIED
426.11 FIRST DEGREE ATRIOVENTRICULAR BLOCK
426.12 MOBITZ (TYPE) II ATRIOVENTRICULAR BLOCK
426.13 OTHER SECOND DEGREE ATRIOVENTRICULAR BLOCK
426.82 LONG QT SYNDROME
427.0 PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
427.1 PAROXYSMAL VENTRICULAR TACHYCARDIA
780.01 COMA
780.09
780.1
780.39
780.97
963.0
965.00
965.01
965.02
965.09
965.1
965.4
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
965.5 POISONING BY PYRAZOLE DERIVATIVES
965.61 POISONING BY PROPIONIC ACID DERIVATIVES
966.1 POISONING BY HYDANTOIN DERIVATIVES
967.0 POISONING BY BARBITURATES
967.1 POISONING BY CHLORAL HYDRATE GROUP
967.2 POISONING BY PARALDEHYDE
967.3 POISONING BY BROMINE COMPOUNDS
967.4 POISONING BY METHAQUALONE COMPOUNDS
967.5 POISONING BY GLUTETHIMIDE GROUP
967.6 POISONING BY MIXED SEDATIVES NOT ELSEWHERE CLASSIFIED
967.8 POISONING BY OTHER SEDATIVES AND HYPNOTICS
967.9 POISONING BY UNSPECIFIED SEDATIVE OR HYPNOTIC
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.
2/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
L28145 Qualitative Drug Screen (4 of 4)
Data Source: Local Coverage Determination for
CPT Codes: 80102, G0431, G0434
Qualitative Drug Screening (L28145)
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.
For monitoring of patient compliance in a drug treatment program, use ICD-9-CM code V71.09 as the primary diagnosis and the specific drug dependence diagnosis
as the secondary diagnosis.
For the monitoring of patients on methadone maintenance and chronic pain patients with opioid dependence, suspected of abusing other illicit drugs, use code V58.69
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.
970.89 POISONING BY OTHER CENTRAL NERVOUS SYSTEM
969.00 POISONING BY ANTIDEPRESSANT, UNSPECIFIED
STIMULANTS
969.01 POISONING BY MONOAMINE OXIDASE INHIBITORS
972.1 POISONING BY CARDIOTONIC GLYCOSIDES AND DRUGS OF
969.02 POISONING BY SELECTIVE SEROTONIN AND NOREPINEPHRINE
SIMILAR ACTION
REUPTAKE INHIBITORS
977.9 POISONING BY UNSPECIFIED DRUG OR MEDICINAL SUBSTANCE
969.03 POISONING BY SELECTIVE SEROTONIN REUPTAKE INHIBITORS
V15.81 PERSONAL HISTORY OF NONCOMPLIANCE WITH MEDICAL
969.04 POISONING BY TETRACYCLIC ANTIDEPRESSANTS
TREATMENT PRESENTING HAZARDS TO HEALTH
969.05 POISONING BY TRICYCLIC ANTIDEPRESSANTS
V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
969.09 POISONING BY OTHER ANTIDEPRESSANTS
V71.09 OBSERVATION OF OTHER SUSPECTED MENTAL CONDITION
969.1 POISONING BY PHENOTHIAZINE-BASED TRANQUILIZERS
969.2 POISONING BY BUTYROPHENONE-BASED TRANQUILIZERS
Limitations:
969.3 POISONING BY OTHER ANTIPSYCHOTICS NEUROLEPTICS AND
A qualitative drug screen is not medically reasonable or necessary to screen for
MAJOR TRANQUILIZERS
the same drug with both a blood and a urine specimen simultaneously.
969.4 POISONING BY BENZODIAZEPINE-BASED TRANQUILIZERS
Medicare regards drug screening for medico-legal purposes (e.g., court-ordered
969.5 POISONING BY OTHER TRANQUILIZERS
drug screening) or for employment purposes (e.g., as a pre-requisite for
969.6 POISONING BY PSYCHODYSLEPTICS (HALLUCINOGENS)
employment or as a requirement for continuation of employment) as not
969.70 POISONING BY PSYCHOSTIMULANT, UNSPECIFIED
medically necessary.
969.71 POISONING BY CAFFEINE
Utilization Guidelines:
969.72 POISONING BY AMPHETAMINES
It is expected that these services would be performed as indicated by current
969.73 POISONING BY METHYLPHENIDATE
medical literature and/or standards of practice. When services are performed in
969.79 POISONING BY OTHER PSYCHOSTIMULANTS
excess of established parameters, they may be subject to review for medical
969.8 POISONING BY OTHER SPECIFIED PSYCHOTROPIC AGENTS
necessity.
969.9 POISONING BY UNSPECIFIED PSYCHOTROPIC AGENT
For the monitoring of patients on methadone maintenance and chronic pain
970.81 POISONING BY COCAINE
patients with opioid dependence, suspected of abusing other illicit drugs, use
ICD-9-CM code V58.69.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
2/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
L28463 RAST Type Tests
CPT Code: 86003
Data Source: Local Coverage Determination for
RAST Type Tests (L28463)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a
patient's 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.
995.0 OTHER ANAPHYLACTIC REACTION
The following ICD-9 Codes apply only to CPT code 86003:
995.1 ANGIONEUROTIC EDEMA NOT ELSEWHERE CLASSIFIED
995.20 UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL
477.0 ALLERGIC RHINITIS DUE TO POLLEN
AND BIOLOGICAL SUBSTANCE
477.1 ALLERGIC RHINITIS DUE TO FOOD
995.22 UNSPECIFIED ADVERSE EFFECT OF ANESTHESIA
477.2 ALLERGIC RHINITIS, DUE TO ANIMAL (CAT) (DOG) HAIR
995.27 OTHER DRUG ALLERGY
AND DANDER
995.29 UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND
477.8 ALLERGIC RHINITIS DUE TO OTHER ALLERGEN
BIOLOGICAL SUBSTANCE
477.9 ALLERGIC RHINITIS CAUSE UNSPECIFIED
995.3 ALLERGY UNSPECIFIED NOT ELSEWHERE CLASSIFIED
493.00 EXTRINSIC ASTHMA UNSPECIFIED
995.60 ANAPHYLACTIC REACTION DUE TO UNSPECIFIED FOOD
493.01 EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS
995.61 ANAPHYLACTIC REACTION DUE TO PEANUTS
493.02 EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION
995.62 ANAPHYLACTIC REACTION DUE TO CRUSTACEANS
493.82 COUGH VARIANT ASTHMA
995.63 ANAPHYLACTIC REACTION DUE TO FRUITS AND VEGETABLES
493.90 ASTHMA UNSPECIFIED
995.64 ANAPHYLACTIC REACTION DUE TO TREE NUTS AND SEEDS
493.91 ASTHMA UNSPECIFIED TYPE WITH STATUS
995.65 ANAPHYLACTIC REACTION DUE TO FISH
ASTHMATICUS
995.66 ANAPHYLACTIC REACTION DUE TO FOOD ADDITIVES
493.92 ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION
995.67 ANAPHYLACTIC REACTION DUE TO MILK PRODUCTS
691.8 OTHER ATOPIC DERMATITIS AND RELATED CONDITIONS
995.68 ANAPHYLACTIC REACTION DUE TO EGGS
708.0 ALLERGIC URTICARIA
995.69 ANAPHYLACTIC REACTION DUE TO OTHER SPECIFIED FOOD
708.8 OTHER SPECIFIED URTICARIA
V15.09 PERSONAL HISTORY OF OTHER ALLERGY OTHER THAN TO MEDICINAL
708.9 UNSPECIFIED URTICARIA
AGENTS
786.07 WHEEZING
*ICD-9-CM CODE 989.5 SHOULD BE REPORTED FOR VENOM HYPERSENSITIVITY.
989.5* TOXIC EFFECT OF VENOM
Utilization Guidelines:
It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess
of established parameters, they may be subject to review for medical necessity.
CPT codes 86001 and 86005 are not covered services.
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.
3/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Data Source: Local Coverage Determination
L29510 Vitamin D Assay Testing
for Vitamin D Assay Testing (L29510)
CPT Code: 82306
LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead
to hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and
reimbursement for these services.
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.
Group 1 Codes:
252.00 HYPERPARATHYROIDISM, UNSPECIFIED
252.01 PRIMARY HYPERPARATHYROIDISM
252.02 SECONDARY HYPERPARATHYROIDISM, NON-RENAL
252.08 OTHER HYPERPARATHYROIDISM
252.1 HYPOPARATHYROIDISM
268.0 RICKETS ACTIVE
268.2 OSTEOMALACIA UNSPECIFIED
268.9 UNSPECIFIED VITAMIN D DEFICIENCY
275.3 DISORDERS OF PHOSPHORUS METABOLISM
275.41 HYPOCALCEMIA
275.42 HYPERCALCEMIA
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
588.81 SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN)
733.00 OSTEOPOROSIS UNSPECIFIED
733.01 SENILE OSTEOPOROSIS
733.02 IDIOPATHIC OSTEOPOROSIS
733.03 DISUSE OSTEOPOROSIS
733.09 OTHER OSTEOPOROSIS
733.90 DISORDER OF BONE AND CARTILAGE UNSPECIFIED
Limitations: For Medicare beneficiaries, screening tests are governed by statute. Vitamin D testing may not be used for routine screening.
Once a beneficiary has been shown to be vitamin D deficient, further testing is medically necessary only to ensure adequate replacement has been
accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors.
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.
7/31/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved