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Introduction �����������������������..�1
Key Points for Diagnosis Coding ��������������.. 2
Medicare Billing ���������������������� 3-13
Successful Laboratory Requisitions
Documentation Requests
Advance Beneficiary Notices
Medicare Secondary Payor
Regence Vitamin D Limitations ����������������14-17
Premera Vitamin D Limitations ����������������18-22
United Healthcare Hepatitis Screening Limitations����...�. 23-28
Washington DSHS Guidelines ����������������29-30
Medicare Coverage Limitation Resources �����������31-38
NCD-LCD Test Code & Price List
Investigation Test Code & Price List
Frequency Test List
Always Non-Covered ICD9-CM Codes
Medicare NCD & LCD Table of Contents ���������..��39-40
Medicare NCD & LCD Listings ��������������.��41-127
Common ICD-9 Codes ���...��������������.��128-130
PACLAB A 2013 BILLING GUIDE: TABLE OF CONTENTS
The Importance of Diagnosis Codes
INTRODUCTION
In today's regulated healthcare climate, diagnosis codes are mandatory. When
requisitions arrive without a valid and covered code or a signed waiver (if
necessary), the Lab might not be reimbursed for our services. Please assist us
by providing this required information at the time you order the test. if you have
any questions regarding this issue, please contact your service representative
or your billing coordinator.
The Balanced Budget Act of 1997 requires physicians to provide diagnostic or
other medical information when ordering services furnished by another entity in
order for payment to be made to the entity furnishing the service. PACLAB is
not allowed to determine what code should be used for the laboratory services.
Only the ordering physician/authorized provider is authorized to determine the
reason that the test is ordered. PACLAB is also not allowed to routinely accept
orders where Advance Beneficiary Notices (ABNs) are not collected when
necessary, or routinely write off tests where an ABN is not obtained. This may
be considered "inducement" under government regulations. However, to assist
the physician's office in determining whether an ABN may be needed, PACLAB
provides ABN assistance through our website www.paclab.com which will help
the physician's staff to determine whether an ABN is required. In addition,
PACLAB provides electronic access to National and Local Coverage Decision
(NCD and LCD) information.
We are pleased to provide various tools designed to help you. These include
staff training, waiver (ABN) forms, waiting room signs, etc.
1 April 2013
� When ordering Medication Levels it is still necessary to provide a medically
necessary diagnosis, symptom or “med monitoring” code (V58.61, V58.69�).
Although it may be obvious that the patient is on medication, Medicare does not allow
turning a test order into an ICD-9 code.
Key Points for Diagnosis Coding
� All requisitions must provide proof of “medical necessity” for each test ordered in the
form of ICD-9 codes, narrative diagnoses or symptoms.
� If the alpha-numeric “ICD-9” code is not known, a narrative diagnosis (full
description or abbreviation) may be written on the requisition.
Example: If the patient's chart indicates atrial fibrillation, but the ICD-9 (427.31) is not known, writing“A-
Fib” on the requisition is acceptable.
**IMPORTANT NOTE: If the patient has Medicare coverage and a Limited Coverage Test is ordered,
the patient will have to sign an Advance Beneficiary Notice (ABN) if only a narrative is provided.
� Diagnosis codes can either be actual diagnoses, current symptoms or abnormal test
results.
Example: The patient has been diagnosed w/ hypothyroidism and the provider orders a TSH,
hypothyroidism (244.9) would be the appropriate diagnosis (ICD-9) assigned.
Example: The patient has been experiencing fatigue and weight gain. The provider wants to run a TSH
to see if the patient is hypothyroid. In this case, fatigue (780.79) and weight gain (783.1) would be the
appropriate narratives or codes to assign.
Example: The patient’s lab results come back w/ an elevated glucose (790.29), a low HCT (285.9) and
an abnormality of their UA (791.9). As a result, the provider adds on a Glycohemoglobin (HgbA1C), an
Iron or Ferritin and a Urine Culture. Therefore the “medical necessity” is proven in the abnormal labs (be
specific), not the original diagnosis. This, again, can be given as either a narrative diagnosis or an ICD-
9 code.
� “RULE OUT”, “POSSIBLE” or “SUSPECTED” are not codeable descriptions.
In the above example, rather than considering "ruling out" hypothyroidism, the symptoms which are
causing the provider to believe that this might be the problem, i.e. fatigue and weight gain, should be
provided.
� V58.61 is for anticoagulant monitoring and V58.69 is for monitoring of other
medications. These codes are acceptable by Medicare, but they cannot be
interchanged.
2 April 2013
Medicare
Billing
3 April 2013
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Patient's date of birth
Successful Laboratory Requisitions, Medicare Billing
The following Medicare billing requirements will assist you to
accurately complete laboratory requisitions. The objective is to
minimize recurring phone calls to our valued clients and service
center employees. Thank you for your attention to detail.
When billing Medicare, the following italicized information is always
required on the laboratory requisition. The additional information is
essential for accurate billing.
Patient's full name
Patient's sex
Patient's Social Security Number (optional)
Insurance ID number (Medicare HIC # + Prefix or suffix
character(s))
Marked Test(s) being ordered with appropriate and valid ICD-
9 for every test ordered
When indicated, a signed and dated ABN-with test(s) listed,
reason(s) specified for possible denial and estimated cost of
test(s) with the patient checking the option desired and the
patient signing and dating the ABN.
Patient's phone number
Patient's full address
Ordering provider full name
Ordering provider signature
Date and time of collection and fasting status
Who is to be billed (circle Medicare)
4 April 2013
Successful Laboratory Requisitions, Medicare Billing
5 April 2013
Documentation Guidelines for Medicare Services
This article is being revised and reprinted from "Medicare B News," Issue 236 dated
April 17, 2007, to ensure that the Noridian Adminstrative Services (NAS) provider and
supplier community has access to recent publications that contain the most current,
accurate and effective information available.
Medical records should be complete, legible, and include the following information:
• Reason for encounter, relevant history, findings, test results, and date of service.
• Assessment and impression of diagnosis.
• Plan of care with date and legible identity of the observer.
• Documentation that supports that the rendering/billing provider indicated on the claim
is the healthcare professional providing the service. (*Note)
• Records should not only substantiate the service performed, but also the required
level of care.
If the physician uses a scribe (an individual taking notes), the scribe needs to fully sign
the note, with their own credentials, followed by the physician’s signature and
credentials.
We, as the Laboratory, perform tests requested for your patients who have Medicare.
We are required, by law, to provide documentation if requested by the Comprehensive
Error Rate Testing (CERT) program by CMS. CERT reviews claims, on a post-
payment review of claims, submitted by our laboratory. These claims could be audited
for documentation to support the rendering/billing provider indicated on the claim.
During the audit process, if documentation is needed, the physician or supplier (lab)
must provide the required documentation within the deadlines stipulated in the written
request from CERT.
The lab receives these CERT requests and must request patient records, progress
notes, etc. from the physician’s office and/or clinic. Therefore, it is critical for each
office/clinic to understand that we have time limits to receive this information and must
respond to Medicare within the timeframe given to the laboratory. Upon receipt of
documentation, CERT reviews the claims and medical records from the
providers/suppliers who submitted the claims, reviewing the claims for compliance
with Medicare coverage, coding, and billing rules.
Below are the guidelines from Medicare to assist in documentation and provide
guidance to follow when ordering Laboratory tests.
Documentation Requests, Medicare Billing
6 April 2013
Documentation Requests, Medicare Billing
By law, Medicare contractors [Medicare Administrative Contractors (MAC) Part B
Carriers and Medicare Administrative Contractors (MAC) Part A Fiscal Intermediaries]
can review any information, including medical records, pertaining to a Medicare claim.
Providers billing Medicare for their services must act in accordance with the following
conditions:
• Document in appropriate office records and/or hospital records each time a covered
Medicare service is provided or ordered. In the case of laboratory test orders, the
exact name of the test(s) being ordered needs to be in the patient's medical record.
When providing concurrent care for hospital or custodial care facility patients,
physicians should identify their specialty in order to help support the necessity. Write
medical information legibly and sign each entry with a legible signature, or ensure that
the provider’s/author’s/observer’s identity is present and legible.
Medical information should be clear, concise, and reflect the patient's condition.
Sign progress notes for hospital and custodial care facility patients with all entries
dated and signed by the healthcare provider who actually examined the patient.
Provide sufficient detail to support diagnostic tests that were furnished and the level of
care billed.
Do not use statements such as “same as above” or ditto marks (“). This is not
acceptable documentation that the service was provided on that date. The “burden of
proof” remains with the provider to substantiate services and/or supplies billed to
Medicare. During the audit process, if documentation is needed, the physician or
supplier must provide the required documentation within the deadlines stipulated in
* Note: Medicare needs to identify primary physicians/practitioners of a service not
only for use in standard claims transactions, but also for review, fraud detection, and
planning policies. In order to accomplish this, NAS (Noridian Administration Services)
must be able to determine and verify the rendering physician/practitioner for each
outpatient service billed to Medicare. It is very important that the individual(s)
performing a billed service is/are identified.
7 April 2013
�
�
�
�
�
�
Advance Beneficiary Notice, Medicare Billing
An Advance Beneficiary Notice (ABN) should be obtained
whenever a provider has reason to believe a procedure could
be denied as not reasonable and necessary. Generally,
services necessitating a signed ABN are those that are
payable in some instances, but not payable in others. These
can include:
The Omnibus Budget Reconciliation Act of 1986 (OBRA)
included a limitation of liability (or waiver of liability) provision
that provided beneficiaries with protection from liability when
they, in good faith, receive services from a Medicare provider
for which Medicare payment is subsequently denied as not
"reasonable and necessary."
Screening Tests
Tests that might be ordered as part of a routine exam (when
the patient does not exhibit evidence of a particular disease)
are not covered.
Please provide an ICD-9
code for each test
ordered for Medicare
patients.
Tests Not Medically Necessary
Tests that are not medically necessary for a diagnosis or
condition - in Medicare's opinion - are not covered.
Laboratory tests that are specifically excluded by the Medicare
program. (e.g., General Health Panels)
Experimental ("Investigational") Tests
Tests designated by the manufacturer as "for research or
investigational use," and thus considered experimental or
investigational, are also not covered by Medicare.
Tests Performed Too Frequently
Tests that are performed more frequently than is
recommended by Medicare are not covered.
Laboratory tests for which Medicare has established either a
National Coverage Decision (NCD) or for which a Medicare
Administrative Contractor (MAC) has established a Local
Coverage Decision (LCD).
8 April 2013
1.
2.
3.
4.
5.
6.
7.
8. Patient must date the ABN.
Advance Beneficiary Notice, Medicare Billing
Please provide the laboratory with a valid Advance
Beneficiary Notice when you have reason to believe
Medicare may deny a procedure as 'medically
unnecessary.'
The procedure for obtaining a Medicare waiver (ABN) is based
on the current list of tests for which Medicare requires an
ICD9 code to consider payment. Please refer to the "Current
Lab Services That Require Proof of Medical Necessity" list. Do
not obtain a Medicare waiver (ABN) for every Medicare
patient, but only for those who may be held liable for the
service.
Medicare is very specific about what elements are required on
an ABN for it to be considered valid. Absence of any of the
required elements invalidates that ABN and is the same as no
ABN at all. Medicare is also very specific about format and
appearance of the ABN. Please take a moment to review the
ABN that follows. The following must be completed on each
ABN obtained:
Patient Name
Date of Birth or other unique identifier as Identification
Number. Must not use Medicare numbers (HICNs) or SSN.
Specific tests the patient was advised could be denied must
be listed in the appropriate column.
The reason these tests may be denied must be listed in the
appropriate column.
The estimated cost of the test(s), to the best of your
knowledge, must be provided in the appropriate column.
Once the information is recorded, ask the patient to read, and
then check Option 1, Option 2, and or Option 3. The patient
must do this.
Patient must sign the ABN.
9 April 2013
Advance Beneficiary Notice, Medicare Billing
10 April 2013
1.
2.
3.
4.
5.
6.
7.
8.
9. Have the patient check Option 1, 2 or 3, and then the patient
must date and sign the form.
The ABN Request Program
Please provide the laboratory with a valid Advance
Beneficiary Notice when you have reason to believe
Medicare may deny a procedure as 'medically
unnecessary.'
PACLAB provides ABN assistance through our website
www.paclab.com. This program will determine if an ABN is
necessary without the need to look through a book or manual.
How to use it:
Go to our website and click on ABN Request.
Select the entity where the testing will be performed. The Bill
Class field should automatically populate with the appropriate
code for that entity.
Enter our workpar (or ?test name, if unknown) for each and
every test the provider has ordered in the first box. Separate
the workpars with a comma or vertical bar leaving no spaces
between characters.
Specific tests the patient was advised could be denied must
be listed in the appropriate column.
In the second box, enter the ICD-9 codes provided on the
requisition, using the same separators with no spaces
between characters.
Click on the Medical Necessity button. The program will
inform you if the test/s require an ABN. If required, an ABN
must be printed out.
Enter the patient’s name and date of birth into the appropriate
fields and click on the Generate Printable ABN button. The
ABN will have the patient’s name, date of birth, and the cost of
the testing listed.
Print out the ABN and explain it to the patient.
11 April 2013
References
Medicare Part B 1999 Basic Billing Manual
Medicare Secondary Payer
Medicare Secondary Payer (MSP) refers to those instances in
which Medicare does not have the primary responsibility for
paying the medical expenses for a Medicare beneficiary.
All Providers should screen Medicare patients to obtain
correct and current health insurance information before
submitting a primary claim to Medicare.
By completing the MSP Questionnaire to initially screen your
Medicare patients, you will help reduce costs to the Medicare
Program as well as administrative costs to your practice.
Requisitions provided to the laboratory should reflect accurate
patient insurance information, including screening for
Medicare Secondary Payer. Laboratory Patient Service Center
employees will provide Medicare Secondary Payer screening
when performing phlebotomy on Medicare beneficiaries.
Physician offices that are unable to provide Medicare
Secondary Payer screening are encouraged to direct their
patients to our Patient Service Centers for this vital
requirement of the Medicare Program.
www.cms.gov/MedicareSecondPayerandYou/
www.noridianmedicare.com/
www.noridianmedicare.com/p-medb/news/faq/msp.html
Medicare B New, Issue 167 "Medicare Secondary Payer"
Hospital Manual-Section 295.1, 301-301.2 January 1999
12 April 2013
DISABILITYProceed only to #9-10
Date of injury/illness: ________/______/_________
Name/Address of WC plan:
Policy or ID #:
Date of accident: ________/______/_________
Type of accident: Automobile or Non-Auto?
Name/Address of no-fault or liability insurer?
Insurance claim number: _______________
Was another party responsible for the accident?
Name/address of any liability insurer?
9. DISABILITY: Are you currently
employed?
Date dialysis began: ________/______/_________
Name/Address of Spouse's Employer
Do you have Group Health Plan coverage based on
your own or a spouse's current employment?
Does employer who has GHP employ 20 or more?
Name/Address of GHP
Policy ID Number
Group ID Number
Name of Policy Holder
Relationship to patient
ESRD (End Stage Renal Dis)Proceed to #11-14
Name/Address of Employer
Date of transplant: ________/______/_________
10. DISABILITY: Is a family
member currently employed?
11. ESRD: Do you have group
health plan coverage
12. ESRD: Have you received a
kidney transplant?
13. ESRD: Have you received
maintenance dialysis treatment?
14. ESRD: Are you within the 30
month coordination period?
NO YES
NO YES
NO YES
NO YES
NO YES
NO YES
5. Is this lab procedure being
done due to a non-work related
accident?
6. Are you entitled to Medicare
based on: circle field(s) to R
7. AGE: Are you currently
employed?
8. AGE: Is your spouse currently
employed?
AGEProceed only to #7-8
NO YES
NO YES
NO YES
NO YES
NO YES
NO YES
4. Is this lab procedure being
done due to a work related
accident/condition?
NO YES
Medicare Secondary Payer (MSP) Questionnaire
Part II
1. Are you receiving Black Lung
Benefits?
2. Are you receiving any gov't
funded research program that
would pay for this service?
3. Has the Dept of Veteran's
Affairs (DVA) agreed to pay for
these procedures?
Medicare Secondary Payor (MSP) Questionnaire (LAB)
Medicare requires the questions below in Part I to be answered by each patient, before Medicare is billed
for medical services. If the answer to any of these questions is "yes," please complete the appropriate
follow-up information in Part II.
Patient Name:
Medicare #: Date of Service:
Part I Circle NO or YES
Date benefits began: ________/______/_________
Which government program and research grant will
pay primary benefits for this lab test(s)?
13 April 2013
Regence
Billing
14 April 2013
252.00-252.08
252.1
263.9
268.2
275.41
275.42
276.3
278.4
268.0, 268.1
275.40, 275.49
571.9
579.0
579.2
579.4
579.9
585.6
585.9
592.0
Rickets
Disorder of calcium metabolism
Chronic liver disease without alcohol
Celiac disease
Blind loop syndrome
Pancreatic Steatorrhea
Intestinal malabsorption
End stage renal disease
Chronic kidney disease
Calculus of kidney
Hypervitaminosis D
REGENCE SUMMARY OF ALLOWED DX CODES FOR VITAMIN D TESTING:
CPT 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
APPENDIX I - ALLOWED FOR CPT 82306 AS OF 9/1/11
Conditions Specifically Associated with Vitamin D Deficiency
Hyperparathyroidism
Hypoparathyroidism
Protein-calorie malnutrition
Osteomalacia
Hypocalcemia
Hypercalcemia
Disorders of phosphorus metabolism
A list of Regence approved codes for VITAMIN D testing is provided below.
Vitamin D Limitations, Regence Billing
Regence has implemented a VITAMIN D testing policy and has greatly reduced the
number of ICD9 codes that they will now cover. This is effective September 1, 2011.
It is the provider’s responsibility to select diagnosis codes carried out to the highest level
of specificity and selected from the ICD-9-CM code book appropriate to the year in which
the service is rendered for the claim(s) submitted.
Regence's VITAMIN D policy should be retained as a reference, but remember that every
code provided on the lab order must be substantiated in the patient’s chart.
If a VITAMIN D test is ordered for a reason that is not considered “medically necessary”
by Regence, the “Non-covered Services Waiver Form” must be provided to and signed by
the patient.
15 April 2013
Vitamin D Limitations, Regence Billing
592.1
733.00
775.4
786.2
780
V70-V77.1
V77.3-V77.8
V77.91
V78-V82.9
135*
252.00-252.08
252.1
268.0
268.1
268.2
270.0*
275.3*
275.40
275.41
275.42
275.49
592.0
592.1
592.9
775.4
Other disorders of calcium metabolism
Calculus of kidney
Calculus of ureter
Urinary calculus, unspecified
Hypocalcemia and hypomagnesemia of newborn
Hypocalcemia
ICD 9-CM and Description - ALLOWED FOR 82652 AS OF 10/1/11
Sarcoidosis* New code added October 1.
Hyperparathyroidism, range
Hypoparathyroidism
Rickets, active
Rickets, late effect
Osteomalacia, unspecified
Fanconi syndrome* New code added October 1.
Familial hypophosphatemia* New code added October 1.
Unspecified disorder of calcium metabolism
Hypocalcemia
Based upon recent additional feedback received from clinicians related to CPT 82652
Vitamin D; 1, 25-dihydroxy, includes fraction(s), if performed, we have expanded the
medical conditions list where we will consider serum testing for calcitriol (1,25[OH]2D)
medically necessary for diagnosis or direct treatment. Effective October 1, the covered
medical conditions include:
Hypocalcemia and hypomagnesemia of newborn
Osteopetrosis
As a reminder, effective September 1, the following International Classification of
Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes are considered not
medically necessary and denied as a provider write-off when billed with CPT 82306:
ICD 9-CM and Description - NOT ALLOWED FOR 82306 or 82652 AS OF 9/1/11
General Symptoms
Persons without reported diagnosis encountered during examination and
Same as above
Same as above
Same as above
CPT 82652 Vitamin D; 1,25 dihydroxy, includes fraction(s), if performed
Vitamin D policy diagnoses expanded for CPT 82652 (1,25[OH]2D)
Osteoporosis
Calculus of ureter
16 April 2013
Vitamin D Limitations, Regence Billing
17 April 2013
Premera
Billing
18 April 2013
010.00 –018.96
135
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
200.80 –200.88
201.00 –201.08
201.10 –201.18
201.20 –201.28
201.40 –201.48
201.50 –201.58
201.60 –201.68
Lymphocytic-histiocytic predominance
Nodular sclerosis
Mixed cellularity
Anaplastic large cell lymphoma
Large cell lymphoma
Other lymphoma variants
Hodgkin’s paragranuloma
Hodgkin’s granuloma
Hodgkin’s sarcoma
Reticulosarcoma
Lymphosarcoma
Burkitt’s tumor or lymphoma
Marginal zone lymphoma
Mantel cell lymphoma
Primary central nervous system lymphoma
PREMERA SUMMARY OF ALLOWED DX CODES FOR VITAMIN D TESTING:
CPT 82306 Vitamin D; 25 hydroxy, includes fraction(s), if performed
ICD9-CM ALLOWED FOR CPT 82306 AS OF 11/12/12
Tuberculous infection, code range
Sarcoidosis
Vitamin D Limitations, Premera Billing
Premera has implemented a VITAMIN D testing policy and has greatly reduced the
number of ICD9 codes that they will now cover. This is effective November 12, 2012.
It is the provider’s responsibility to select diagnosis codes carried out to the highest level
of specificity and selected from the ICD-9-CM code book appropriate to the year in which
the service is rendered for the claim(s) submitted.
Premera's VITAMIN D policy should be retained as a reference, but remember that every
code provided on the lab order must be substantiated in the patient’s chart. Premera’s
policy can be reviewed in its entirety at:
https://www.premera.com/stellent/groups/public/documents/medicalpolicy/cmi_134366.ht
m#P34_328
If a VITAMIN D test is ordered for a reason that is not considered “medically necessary”
by Regence, the “Non-covered Services Waiver Form” must be provided to and signed by
the patient.
A list of Premera approved codes for VITAMIN D testing is provided below.
19 April 2013
Vitamin D Limitations, Premera Billing
201.70 –201.78
201.90 –201.98
202.00 –202.08
202.10 –202.18
202.20 –202.28
202.30–202.38
202.40 –202.48
202.50 –202.58
202.60 –202.68
202.70 –202.78
202.80 –202.88
202.90 –202.98
252.00 – 252.08
252.1
262
263.0
263.1
263.9
268.0
268.1
268.2
268.9
270.0 –270.9
275.3
275.40
275.41
275.42
278.4
278.8
278.8
359.5
414.00
414.01
414.05
414.06
414.3
555.0-555.9
571.2
571.5
571.6
576.8
Biliary cirrhosis
Other specified disorders of biliary tract
Coronary atherosclerosis of unspec. type of bypass graft
Coronary atherosclerosis of native coronary artery of transplanted heart
Coronary atherosclerosis due to lipid rich plaque
Regional enteritis, code range
Alcoholic cirrhosis of liver
Cirrhosis of liver without mention of alcohol
Hypervitaminosis D
Hyperalimentation
Other hyperalimentation
Myopathy in endocrine diseases
Coronary atherosclerosis of unspec type of vessel, native or graft
Coronary atherosclerosis of native coronary artery
Unspecified vitamin D deficiency
Disorders of amino-acid transport and metabolism, code range
Disorders of phosphorus metabolism
Disorder of calcium metabolism, unspecified
Hypocalcemia
Hypercalcemia
Malnutrition of moderate degree
Malnutrition of mild degree
Unspecified protein-calorie malnutrition
Rickets, active
Ricketts, late effect
Osteomalacia, unspecified
Peripheral T-cell lymphoma
Other lymphomas
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue
Hyperparathyroidism, code range
Hypoparathyroidism
Other severe, protein-calorie malnutrition
Mycosis Fungoides
Sezary’s disease
Malignant histiocytosis
Leukemic reticuloendotheliosis
Letterer-Siwe disease
Malignant mast cell tumors
Lymphocytic depletion
Hodgkin’s disease, unspecified
Nodular lymphoma
20 April 2013
Vitamin D Limitations, Premera Billing
579.0-579.9
585.3–585.6
585.9
588.0
592.0
592.1
592.9
594.0
594.1
594.2
594.8
594.9
696.1
710.0
710.3
729.1
733.00
733.01
733.02
733.03
733.09
733.90
756.51
756.52
775.4
* V58.65
* V58.69
010.00 –018.96
135
252.00 – 252.08
252.1
268.0
268.1
268.2
270.0
275.3
275.40
Rickets, active
Ricketts, late effect
Osteomalacia, unspecified
Fanconi syndrome
Disorders of phosphorus metabolism
Disorder of calcium metabolism, unspec
CPT 82652 Vitamin D; 1,25 dihydroxy, includes fraction(s), if performed
ICD9-CM ALLOWED FOR CPT 82652 AS OF 11/12/12
Tuberculous infection, code range
Sarcoidosis
Hyperparathyroidism, code range
Hypoparathyroidism
Osteogenesis imperfecta
Osteopetrosis
Hypocalcemia and hypomagnesemia of newborn
Long-term (current) use of steroids
Long-term (current) use of other medications
* NOTE: Report with 268.2, Osteomalacia, unspecified
Osteoporosis, unspecified
Senile osteoporosis
Idiopathic osteoporosis
Disuse osteoporosis
Other osteoporosis
Disorder of bone and cartilage unspecified
Other lower urinary tract calculus
Calculus of lower urinary tract, unspecified
Other psoriasis
Systemic lupus erythematosus
Dermatomyositis
Myalgia and myositis unspecified
Calculus of kidney
Calculus of ureter
Urinary calculus unspecified
Calculus in diverticulum of bladder
Other calculus in bladder
Calculus in urethra
Intestinal malabsorption
Chronic kidney disease, code range
Chronic kidney disease, unspecified
Renal osteodystrophy
21 April 2013
Vitamin D Limitations, Premera Billing
275.41
278.8
585.3–585.6
592.0
592.1
592.9
756.51
756.52
775.4
Osteogenesis imperfecta
Osteopetrosis
Hypocalcemia & hypomagnesemia of newborn
Hypocalcemia
Hyperalimentation
Chronic kidney disease, code range
Chronic kidney disease, code range
Calculus of ureter
Urinary calculus unspecified
22 April 2013
United Healthcare (UHC)
Billing
23 April 2013
Hepatitis Screening Limitations, United Healthcare (UHC)
CPT 86803 Hepatitis C antibody
CPT 86804 Hepatitis C antibody; confirmatory test (eg, immunoblot)
CPT 87340 Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple step method; hepatitis B surface antigen (HBsAG)
CPT 87341 Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple step method; hepatitis B surface antigen (HBsAG)
neutralization
CPT 87350 Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple step method; hepatitis Be antigen (HBeAG)
CPT 86709 Hepatitis A antibody (HAAb); IgM antibody
UHC has implemented a Hepatitis Screening testing policy and has greatly reduced the
number of ICD9 codes that they will now cover. This is effective April 1, 2012.
It is the provider’s responsibility to select diagnosis codes carried out to the highest level
of specificity and selected from the ICD-9-CM code book appropriate to the year in which
the service is rendered for the claim(s) submitted.
UHC's Hepatitis Screening policy should be retained as a reference, but remember that
every code provided on the lab order must be substantiated in the patient’s chart.
United’s policy can be reviewed in its entirety at:
https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-
US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Tools%20and%20Resources/Polici
es%20and%20Protocols/Medical%20Policies/Medical%20Policies/Hepatitis_Screening.p
df
A list of UHC approved codes for Hepatis Screening testing is provided below.
UHC SUMMARY OF "PROVEN" DX CODES FOR HEPATITIS SCREENING TESTING:
APPLICABLE CODES: "The codes listed in this policy are for reference purposes only.
Listing of a service or device code in this policy does not imply that the service described
by this code is a covered or non-covered health service. Coverage is determined by the
benefit document. This list of codes may not be all inclusive."
CPT 86704 Hepatitis B core antibody (HBcAB); total
CPT 86705 Hepatitis B core antibody (HBcAB); IgM antibody
CPT 86706 Hepatitis B surface antibody (HBsAB)
CPT 86707 Hepatitis Be antibody (HBeAB)
CPT 86708 Hepatitis A antibody (HAAb); total
24 April 2013
Hepatitis Screening Limitations, United Healthcare (UHC)
Proven
Diagnosis Code
Description
042 Human immunodeficiency virus [HIV] disease
054.10-054.19 Herpes zoster with other nervous system complications
070.0-070.9 Viral hepatitis
078.10 Viral warts, unspecified
078.11 Condyloma acuminatum
078.19 Other specified viral warts
079.4 Human papillomavirus in conditions classified elsewhere and of unspecified site
090.0-090.9 Congenital syphilis
091.0-091.9 Early syphilis, symptomatic
092.0 Early syphilis, latent, serological relapse after treatment
092.9 Early syphilis, latent, unspecified
093.0-093.9 Cardiovascular syphilis
094.0-094.9 Neurosyphilis
095.0-095.9 Other specified forms of late symptomatic syphilis
096 Late syphilis, latent
097.0 Late syphilis, unspecified
097.1 Latent syphilis, unspecified
097.9 Syphilis, unspecified
098.0-098.89 Gonococcal infections
099.0-099.9 Other venereal disease
131.00-131.9 Trichomoniasis
135 Sarcoidosis
286.0-286.4,
286.6-286.9
Coagulation defects
304.00-304.93 Drug dependence
456.0 Esophageal varices with bleeding
456.1 Esophageal varices without mention of bleeding
555.0-555.9 Regional enteritis
556.0-556.5,
556.8, 556.9
Ulcerative colitis
571.0 Alcoholic fatty liver
571.1 Acute alcoholic hepatitis
571.2 Alcoholic cirrhosis of liver
571.3 Unspecified alcoholic liver damage
571.5 Cirrhosis of liver without mention of alcohol
571.6 Biliary cirrhosis
571.8 Other chronic nonalcoholic liver disease
25 April 2013
Hepatitis Screening Limitations, United Healthcare (UHC)
571.9 Unspecified chronic liver disease without mention of alcohol
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
608.4 Other inflammatory disorder of male genital organs
614.9 Unspecified inflammatory disease of female pelvic organs and tissues
616.10 Vaginitis and vulvovaginitis, unspecified
616.11 Vaginitis and vulvovaginitis in diseases classified elsewhere
631 Other abnormal product of conception
632 Missed abortion
633.00-633.91 Ectopic pregnancy
634.00-634.92 Spontaneous abortion
635.00-635.92 Legally induced abortion
636.00-636.92 Illegally induced abortion
637.00-637.92 Unspecified abortion
638.0-638.9 Failed attempted abortion
639.0-639.9 Complications following abortion and ectopic and molar pregnancies
640.00-640.93 Hemorrhage in early pregnancy
641.00-641.93 Antepartum hemorrhage, abruptio placentae and placenta previa
642.00-642.94 Hypertension complicating pregnancy, childbirth and the puerperium
643.00-643.93 Excessive vomiting in pregnancy
644.00-644.21 Early or threatened labor
645.10-645.23 Late pregnancy
646.00-646.93 Other complications of pregnancy, not elsewhere classified
647.00-647.94 Infectious and parasitic conditions in the mother classifiable elsewhere, but
complicating pregnancy, childbirth or the puerperium
648.00-648.94 Other current conditions in the mother classifiable elsewhere, but complicating
pregnancy, childbirth or the puerperium
649.00-649.73 Other conditions or status of the mother classifiable elsewhere, but
complicating pregnancy, childbirth or the puerperium
650 Normal delivery
651.00-651.93 Multiple gestation
652.00-652.93 Malposition and malpresentation of fetus
653.00-653.93 Disproportion
654.00-654.94 Abnormality of organs and soft tissues of pelvis
655.00-655.93 Known or suspected fetal abnormality affecting management of mother
656.00-656.93 Other known or suspected fetal and placental problems affecting management
of mother
657.00-657.03 Polyhydramnios
658.00-658.93 Other problems associated with amniotic cavity and membranes
26 April 2013
Hepatitis Screening Limitations, United Healthcare (UHC)
659.00-659.93 Other indications for care or intervention related to labor and delivery, not
elsewhere classified
660.00-660.93 Obstructed labor
661.00-661.93 Abnormality of forces of labor
662.00-662.33 Long labor
663.00-663.93 Umbilical cord complications
664.00-664.94 Trauma to perineum and vulva during delivery
665.00-665.94 Other obstetrical trauma
666.00-666.34 Postpartum hemorrhage
667.00-667.14 Retained placenta or membranes, without hemorrhage
668.00-668.94 Complications of the administration of anesthetic or other sedation in labor and
delivery
669.00-669.94 Other complications of labor and delivery, not elsewhere classified
670.00-670.84 Major puerperal infection
672.00-672.04 Pyrexia of unknown origin during the puerperium
673.00-673.84 Obstetrical pulmonary embolism
674.00-674.04 Cerebrovascular disorders in the puerperium
674.80-674.94 Other and unspecified complications of puerperium, not elsewhere classified
696.0 Psoriatic arthropathy
696.1 Other psoriasis and similar disorders
714.0 Rheumatoid arthritis
714.1 Felty's syndrome
714.2 Other rheumatoid arthritis with visceral or systemic involvement
714.81 Rheumatoid lung
714.89 Other specified inflammatory polyarthropathies:other
714.9 Unspecified inflammatory polyarthropathy
720.0 Ankylosing spondylitis
720.9 Unspecified inflammatory spondylopathy
790.4 Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase
794.8 Nonspecific abnormal results of function study of liver
959.14 Other injury of external genitals
996.82 Complications of transplanted liver
V01.6 Contact with or exposure to venereal diseases
V01.79 Contact with or exposure to other viral diseases
V02.60-V02.69 Viral hepatitis carrier
V02.7 Carrier or suspected carrier of gonorrhea
V02.8 Carrier or suspected carrier of other venereal diseases
V08 Asymptomatic human immunodeficiency virus [HIV] infection status
V22.0-V22.2 Normal pregnancy
V23.0-V23.3 Supervision of high-risk pregnancy
27 April 2013
Hepatitis Screening Limitations, United Healthcare (UHC)
V23.41 Supervision of pregnancy with history of pre-term labor
V23.49 Supervision of pregnancy with other poor obstetric history
V23.5 Pregnancy with other poor reproductive history
V23.7 Insufficient prenatal care
V23.81-V23.86,
V23.89
Supervision of high-risk pregnancy
V23.9 Unspecified high-risk pregnancy
V24.0-V24.2 Postpartum care and examination
V26.29 Other investigation and testing
V28.2 Other antenatal screening based on amniocentesis
V28.81-V28.89 Other specified antenatal screening
V28.9 Unspecified antenatal screening
V42.0-V42.9 Organ or tissue replaced by transplant
V45.11 Renal dialysis status
V56.0 Encounter for extracorporeal dialysis
V56.8 Encounter other dialysis
V58.11 Encounter for antineoplastic chemotherapy
V58.2 Blood transfusion, without reported diagnosis
V59.01-V59.6,
V59.8-V59.9
Donors of other or unspecified organ or tissue
V69.2 High-risk sexual behavior
V71.5 Observation following alleged rape or seduction
V72.42 Pregnancy examination or test, positive result
V74.5 Screening examination for venereal disease
V83.01-V83.02 Hemophilia A carrier
V87.41 Personal history of antineoplastic chemotherapy
V87.46 Personal history of immunosuppressive therapy
V91.00 -V91.99 Multiple gestation placenta status
28 April 2013
Billing
Washington Public Assistance/DSHS
29 April 2013
Guidelines, Washington Public Assistance/DSHS
HIV tests: DSHS only covers following ICD-9 codes:
042 - Human immunodeficiency virus (HIV)
079.53 - Human immunodeficiency virus, type 2 (HIV-2)
V01.79 - Contact or exposure to other viral diseases
V08 - Asymptomatic HIV infection status
V22.0, V22.1- Pregnancy
V28.89-Other Specified Antenatal Screening
References
All of the above information can be found in the Billing Instructions for Physician-Related
Services. This is available online at:
http://hrsa.dshs.wa.gov/billing/documents/provideroneguide/providerone_billing_and_resource_gui
de.pdf
Preventative Physicals: DSHS only covers preventative physicals for children up to
the age of 18. DSHS does not cover preventative physicals for adults.
Family Planning Only Coverage: DSHS will only cover services associated with
contraception (ICD-9 codes V25.0-V25.9, except V25.3).
Pap Smears: DSHS will cover one routine Pap smear per patient, per calendar year.
DSHS considers routine Pap smears to be those billed with an ICD-9 code of V76.2,
V72.31, V76.47, or V25.40 - V25.49.
“Screening” Testing: DSHS does not cover screening lab work. Therefore, an actual
diagnosis or symptom ICD-9 code must be provided for all lab work to prove medical
necessity.
Monitoring Patient Medications: If monitoring the patient’s medication, the “med
monitoring” ICD-9 codes (V58.61 - V58.69) are to be used as secondary diagnosis
codes only. Per DSHS, the reason for the medication use must be given as the
primary ICD-9 code.
Prenatal Care: If a patient is being seen for prenatal care , and lab work is ordered,
the diagnosis codes V22.0 (patient’s 1st
pregnancy) & V22.1 (any subsequent
pregnancy) are acceptable per DSHS, but V22.2 is not.
30 April 2013
Medicare Coverage Limitation Resources
31 April 2013
Workpar Description CPT4 Eff Date Est Fee
AFP Alpha Feto-protein 82105 (NCD) 11/25/2002 $ 60.00 BTNP B-Type Natriuretic
Peptide
83880 (LCD) 7/25/2011 $ 153.00
CA125 CA125 86304 (NCD) 11/25/2002 $ 62.00 CA15-3 CA15-3 86300 (NCD) 11/25/2002 $ 85.00 CA19-9 CA19-9 86301 (NCD) 11/25/2002 $ 75.00 CA27.29 CA27-29 86300 (NCD) 11/25/2002 $ 66.00 CBC CBC (All complete Blood
Counts)
85021-85028
(NCD)
11/25/2002 $ 44.00
CEA CEA 82378 (NCD) 11/25/2002 $ 54.00 PAP SMEARS Cervical Smears 88150 (LCD) 1996 Client Services CHO Cholesterol 82465 (NCD) 11/25/2002 $ 11.00 UA.ID Culture, Organism ID 87088 (NCD) 11/25/2002 $ 81.00 CURNNS Culture Urine Colony
Count
87086 (NCD) 11/25/2002 $ 58.00
DIF Differential (Blood
Counts), Manual
85007-85008
(NCD)
11/25/2002 $ 62.00
DIG Digoxin 80162 (NCD) 11/25/2002 $ 47.00 DLDL Direct LDL 83721 (NCD) 11/25/2002 $ 58.00 FERR Ferritin 82728 (NCD) 11/25/2002 $ 46.00 FREE T4 Free T4 84439 (NCD) 11/25/2002 $ 44.00 FRUCTO Fructosamine 82985 (NCD) 11/25/2002 $ 53.00 GGT Gamma
Glutamyltransferase
82977 (NCD) 11/25/2002 $ 11.00
GLU Glucose 82947-82948,
82962 (NCD)
11/25/2002 $ 11.00
GLHGB Glycohemoglobin 83036 (NCD) 11/25/2002 $ 45.00 HCG-QUANT HCG Quantitative 84702 / 84703
(NCD)
11/25/2002 $ 52.00
HDL HDL 83718 (NCD) 11/25/2002 $ 41.00 HCT Hematocrit (Including
Spun)
85013-85014
(NCD)
11/25/2002 $ 42.00
HGB Hemoglobin 85018 (NCD) 11/25/2002 $ 42.00 AUT Hemogram, Automated 85021, 85027
(NCD)
11/25/2002 $ 42.00
HEPACU Hepatitis Panel, Acute 80074 (NCD) 11/25/2002 $ 138.00 12HIVR HIV (Virology Serology) 86703 (NCD) 11/25/2002 $ 55.00
HIVQBD HIV-1 Ultrasensitive RNA 87536 (NCD) 11/25/2002 $ 355.00
HIVUS HIV-1, Ultrasensitive
Quant by PCR
87536 (NCD) 11/25/2002 $ 372.00
HIV2AB HIV-2 Antibody, Elisa 86702 (NCD) 11/25/2002 $ 389.00 1HIVWB HIV-1 Western Blot 86689 (NCD) 11/25/2002 $ 245.00 Multiple HIV-2, Amplified Probe 87538 (NCD) 11/25/2002 Client Services Multiple HIV-2, Direct Probe 87538 (NCD) 11/25/2002 Client Services Multiple HIV-2, Quant 87539 (NCD) 11/25/2002 Client Services HYPOA Hypothyroid Profile 84479,84436,
84443 (NCD)
11/25/2002 $ 133.00
IRON.BIND Iron Binding Capacity 83550 (NCD) 11/25/2002 $ 40.00 IRN Iron, Total 83540 (NCD) 11/25/2002 $ 40.00
NATIONAL COVERAGE DECISION AND LOCAL COVERAGE DECISION TEST LIST AND PRICES
32 April 2013
Workpar Description CPT4 Eff Date Est Fee
NATIONAL COVERAGE DECISION AND LOCAL COVERAGE DECISION TEST LIST AND PRICES
LIPID Lipid Profile 80061 (NCD) 11/25/2002 $ 44.00 MAG Magnesium 82735 (LCD) 4/16/2006 $ 40.00 B.NTX N-Telopeptides (NTX) 82523 (NCD) 11/25/2002 $ 116.00 OC.BLD Occult Blood 82270 (NCD) 11/25/2002 $ 55.00 PTT Partial Thromboplastin
Time
85730 (NCD) 11/25/2002 $ 41.00
PLT Platelet Count 85595 (NCD) 11/25/2002 $ 42.00 PT Prothrombin Time 85610 (NCD) 11/25/2002 $ 41.00 PSA PSA 84153 (NCD) 11/25/2002 $ 54.00 T3UP T3 Uptake 84479 (NCD) 11/25/2002 $ 45.00 T4 T4 by Icma 84436 (NCD) 11/25/2002 $ 44.00 BTB Thyroid Profile 84479, 84436
(NCD)
11/25/2002 $ 89.00
TRANSFERRIN Transferrin 84466 (NCD) 11/25/2002 $ 62.00 TRIG Triglycerides 84478 (NCD) 11/25/2002 $ 11.00 TSH TSH 84443 (NCD) 11/25/2002 $ 45.00 UA Urinalysis 81003 (LCD) 10/1/2005 $ 39.00 VDOH Vitam D, 25-Hydroxy 82306 (LCD) 11/14/2011 $ 88.00 VITD23 Vitamin D2/D3, 25-
Hydroxy
82306 (LCD) 11/14/2011 $ 186.00
VIDD Vitamin D (1, 25-
DiHydroxy
82652 (LCD) 11/14/2011 $ 128.00
WBC White Cell Count 85048 (NCD) 11/25/2002 $ 42.00
Reviewed: April 2013
33 April 2013
Workpar Description CPT4 Eff Date Est Fee
21HYAB 21 Hydroxylase
Antibodies
83519 Investigational $ 222.00
APOLA, APOLB Apolipoprotein A & B 82172 Never Covered $ 115.00
ADH Arginine Vasopressing
Hormone
84588 Investigational $ 149.00
ADIPA Adiponectin 83520 Investigational $ 621.00 C2 C2 Complement
Component
86160 Investigational $ 187.00
C3AL C3AL 86160 Investigational $ 297.00 C7SP Complement Component
C7
86160 Investigational $ 356.00
C9CSP Complement Component
C9
86160 Investigational $ 364.00
CAMPAB Campylobacter Jejuni
Antibody
86625 Investigational $ 435.00
multiple Cellular Function Assay
Involving Stimulation
86352 Never Covered Client Services
CHROMA Chromogranin A 86316 Investigational $ 178.00 CYSTICERCUS.AB Cysticercus AB 86682 Investigational $ 209.00
DENGUE Dengue Fever Virus AB,
IGG & IGM
86790 x 2 Investigational $ 197.00
EPIP4A Human Epididymis
Protein
86305 Never Covered $ 634.00
FTABGA Francisella Tularensis AB
Igg
86668 Investigational $ 143.00
FTABMA Francisella Tularensis AB
Igm
86668 Investigational $ 147.00
FTAGMA Francisella Tularensis
ABS Igg & Igm
86668 x2 Investigational $ 227.00
FCORTS Cortisol, Serum Free 82530 Investigational $ 374.00 GM1.AB GM 1 Anitbody Panel 83516 x 4 Investigational $ 620.00 GM1ABS Ganglioside (GM1) ABS,
IGG & IGM
83516 x 2 Investigational $ 254.00
GM1COM Ganglioside Asialo GM1
GM2
83516 Investigational $ 410.00
HEPDAB Hepatitis D Virus
Antibody, Total EIA
86692 Investigational $ 193.00
HIST Histamine 83088 Investigational $ 153.00 HISTP Histamine, Plasma 83088 Investigational $ 153.00 HIST-U Histamine, Urine 83088 Investigational $ 153.00 HIV2WB HIV-2 Antibody, IB 86689 Investigational $ 292.00 INHB Inhibin B 83520 Investigational $ 388.00 LPA.MAYO Lipoprotein (A) 82172 Never Covered $ 62.00
LEPTNA Lysozyme 83520 Investigational $ 322.00 MUR Myelin Basic Protein 85549 Investigational $ 111.00 MBP Maternal Screen,
Integrated Spec #1
83873 Investigational $ 135.00
INVESTIGATIONAL TEST LIST AND PRICES: REQUIRE ABN EVERY TIME THEY ARE ORDERED
34 April 2013
Workpar Description CPT4 Eff Date Est Fee
INVESTIGATIONAL TEST LIST AND PRICES: REQUIRE ABN EVERY TIME THEY ARE ORDERED
MSSIS2 Maternal Screen,
Sequential Spec #2
82105, 84702,
82677, 86336
Investigational $ 475.00
MSSS2 Maternal Screen,
Sequential Spec #2
82105, 84702,
82677, 86336
Investigational $ 475.00
MYAJO1 Phospholipids, serum or
Plasma
83516 x 7, 86235
x3
Investigational $ 404.00
NEUIGG Neuronal Antibodies Igg
by
83516 Investigational $ 557.00
NMRLP NMR Lipoprofile 83704 Never Covered $ 159.00
NMR630 NMR Lipoprofile Test
(LDL-P Only)
83704 Never Covered $ 138.00
NSECA Neuron Specific Enolase,
CSF
86316 Investigational $ 161.00
NSEN Plasminogen Act Inhib-1,
4G/5G
86316 Investigational $ 171.00
PCALTA Procalcitonin 84145 Never Covered $ 633.00
PHOSPHO T-3 Reverse 84311 Investigational $ 147.00 T3REV Vascular Endothelial
Growth Factor
84482 Investigational $ 138.00
TRYPTS Tryptase 83520 Investigational $ 478.00 B.VAPCT1 Lipo, Frac 83701 Never Covered $ 92.00
B.ASAWK1 Thromboxane
Metabolites
84431 Never Covered $ 717.00
VEGF Vascular Endothelial
Growth Factor
83520 Investigational $ 897.00
VGCCAB Voltage Gated Calcium
Chanel Ab
83519 Investigational $ 969.00
Reviewed: April 2013
35 April 2013
Description CPT4 Frequency Covered Covered Diagnosis
Glycated Hemoglobin 83036 1 every 3 months See NCD detail
Glucose 82947 1 per year V77.1 Special screening for endocrine,
nutritional, metabolic, and immunity
disorders; diabetes mellitus
Occult Blood (Fecal) 82270, 82274 1 per year V76.51 Special screening for malignant
neoplasms of colon
Pap Smear 1 every 2 years V76.2 Special screening for malignant
neoplasms of the cervix
V15.89 Other specified personal history
presenting hazards to health
V76.47 Special Screening for malignant
neoplasms of the vagina
PSA 84153 1 per year for men
over 50 years of age
V76.44 Special screening for malignant
neoplasms of prostate
LIPID 80061 1 every 5 years V81.0 Special screening for ischemic
heart disease
V81.1 Special screening for
hypertension
V81.2 Special screening for other &
unspecified cardiovascular conditions
�
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FREQUENCY TEST LIST: IF ANY OF THESE TEST(S) ARE REQUIRED TO BE RUN MORE OFTEN
THAN THE ALLOWABLE FREQUENCIES LISTED, THEY MUST BE DIAGNOSTIC OR HAVE AN ABN
FOR FREQUENCY.
***LIPID PANEL FREQUENCY LIMITATION*** NCD 190.23 Summary for Lipid Testing
Routine screening is generally not covered by Medicare
Borderline high total or LDL cholesterol levels: Lipid panel is reasonable on an
annual basis.
First year of anti-lipid dietary or pharmacologic therapy.
When evaluating non-specific chronic abnormalities of the liver, lipid panel would
generally not be indicated more than twice per year.
* One component of the panel or a measured LDL may be reasonable up to 6
times the first year.
* When documentation supports marked elevations or changes in anti-lipid
therapy due to inadequate initial patient response to dietary or pharmacologic
therapy, more frequent total cholesterol, HDL cholesterol, LDL cholesterol and
triglyceride testing may be indicated.
* After treatment goals are established: LDL cholesterol or total cholesterol may
be measured three times yearly.
Long-term anti-lipid dietary or pharmacologic therapy: Lipid panel is reasonable
on an annual basis.
If no dietary or pharmacologic therapy is advised, monitoring is not necessary.
36 April 2013
Code
798.0-798.9
V15.85
V16.1
V16.2
V16.40
V16.50
V16.51
V16.52
V16.59
V16.6
V16.7
V16.8
V16.9
V17.0-V17.3
V17.41
V17.49
V17.5-V17.89
V18.0
V18.11
V18.19
V18.2-V18.4, V18.51,
V18.59,V18.61, V18.69,
V18.7-V18.9
V19.0-V19.8
V20.0-V20.2
V20.31
Family history of malignant neoplasm, other
Family history of malignant neoplasm, leukemia
Family history of malignant neoplasm, other lymphatic and
Non-covered ICD-9-CM Codes for All NCD Edits, Medicare Billing
Per Medicare: This section lists codes that are never covered. If a code from this section
is given as the reason for the test, the test may be billed to the Medicare beneficiary
without billing Medicare first because the service is not covered by statute, in most
instances because it is performed for screening purposes and is not within an exception.
The beneficiary, however, does have a right to have the claim submitted to Medicare,
upon request.
The individual ICD-9-CM codes included in code ranges in the table below can be viewed
on CMS’ website under Downloads: Lab Code List. The link is:
http://www.cms.hhs.gov/CoverageGenInfo
Family history of malignant neoplasm, urinary organs
Family history of malignant neoplasm, kidney
Non-covered ICD-9-CM Codes for All NCD Edits:
Sudden death, cause unknown
Family history of malignant neoplasm, bladder
Description
Personal history of contact with and (suspected) exposure to potentially
hazardous body fluidsFamily history of malignant neoplasm, trachea, bronchus, and lung
Family history of malignant neoplasm, other respiratory and
Family history of malignant neoplasm, genital organs
Health supervision of infant or child
Family history of malignant neoplasm, other specified malignant
Family history of malignant neoplasm, unspecified malignant
Family history of certain chronic disabling diseases
Family history of sudden cardiac death (SCD)
Family history of other cardiovascular diseases
Family history of asthma; other chronic respiratory conditions
arthritis;other musculoskeletal diseases
Family history of diabetes mellitus
Family history of multiple endocrine neoplasia (MEN) syndrome
Family history of other endocrine and metabolic diseases
Family history of anemia; other blood disorders; mental retardation;
colonic polyps; other digestive disorders; polycystic kidney; other
kidney diseases; other genitourinary diseases; infectious and parasitic
diseases; genetic disease carrier
Family history of other conditions
Health supervision for newborn under 8 days old
37 April 2013
V20.32
V28.0-V28.9
V50.0-V50.9
V53.2
V60.0-V60.6
V60.81
V60.89
V60.9
V62.0
V62.1
V65.0
V65.11
V65.19
V68.0-V68.9
V70.0-V70.9
V73.0-V73.6
V73.81
V73.88-V73.89
V73.98-V73.99
V74.0-V74.9
V75.0-V75.9
V76.0
V76.3
V76.42-V76.43, V76.45-
V76.47, V76.49, V76.50,
V76.52, V76.81, V76.89,
V76.9V77.0
V77.2-V77.99
V78.0-V78.9
V79.0-V79.9
V80.01
V80.09
V80.1-V80.3
V81.3-V81.6
V82.0-V82.6, V82.71,
V82.79, V82.81, V82.89,
V82.9
Healthy persons accompanying sick persons
Health supervision for newborn 8 to 28 days old
Encounter for antenatal screening of mother
Elective surgery for purposes other than remedying health states
Hearing aid
Lack of housing; inadequate housing; lack of material resources;
person living alone; no other household person able to render care;
holiday relief care; and person living in residential institutionFoster care (status)
Other specified housing or economic circumstances
Unspecified housing or economic circumstances
Unemployment
Adverse effects of work environment
Special screening for malignant neoplasms, bladder
Pediatric pre-birth visit for expectant parent(s)
Other person consulting on behalf of another person
Encounters for administrative purposes
General medical examinations
Special screening examinations for viral and chlamydia diseases
Special screening examinations for Human papillomavirus (HPV)
Other specified chlamydial and viral diseases
Unspecified chlamydial and viral disease
Special screening examinations for bacterial and spirochetal diseases
Special screening examination for other infectious diseases
Special screening for malignant neoplasms, respiratory organs
Special screening for other neurological conditions
Special screening for glaucoma and other eye conditions; ear
Special screening for cardiovascular, respiratory, and genitourinary
diseases
Special screening for other conditions
Special screening for malignant neoplasms,(sites other than breast,
cervix, and rectum)
Special screening for endocrine, nutrition, metabolic, and immunity
Special screening for endocrine, nutrition, metabolic, and immunity
Special screening for disorders of blood and blood-forming organs
Special screening for mental disorders
Special screening for traumatic brain injury
38 April 2013
NCD & LCD WASHINGTON A
2013
NCD & LCD
Washington
Medicare A
39 April 2013
Page
Alpha Fetoprotein; Serum ���������������� NCD 41-42
Blood Counts ���������������������� NCD 43-47
B-Type Natriuretic Peptide (BNP) ������������� LCD 48-49
CA125 �������������������������� NCD 50
CA 15-3/CA 27.29 ��������������������� NCD 51
CA 19-9 ������������������������� NCD 52
CEA ��������������������������� NCD 53
Collagen Cross Links (NTX) ���������������� NCD 54
Digoxin Therapeutic Drug Assay(Any Source) ������� NCD 55-57
Gamma Glutamyltransferase (GGT) ������������ NCD 58-61
Glycated Hemoglobin & Glycated Protein ��������� NCD 62-63
Glucose Testing (Blood) ����������������� NCD 64-67
HCG Quantitative �������������������� NCD 68
Hepatitis Panel, Acute ������������������ NCD 69
Human Immunodeficiency Virus (HIV)
Viral Load Diagnosis ����������������� NCD 70-73
Human Immunodeficiency Virus (HIV) Prognosis ������ NCD 74
Iron Studies, Serum ������������������� NCD 75-78
Lipid Profile & Cholesterol Testing ������������ NCD 79-81
Magnesium ����������������������� LCD 82-87
Occult Blood, Feces Screening �������������� NCD 88-90
Prostate Specific Antigen (PSA) �������������� NCD 91
Prothrombin Time (PT) ������������������ NCD 92-99
Partial Thromboplastin Time (PTT) ������������ NCD 100-105
Thyroid Testing ��������������������� NCD 106-109
Urinalysis ������������������������ LCD 110-123
Urine Culture ���������������������� NCD 124-125
Vitamin D������������������������ LCD 126-127
NCD & LCD WASHINGTON A
40 April 2013
National Coverage Decision November 25, 2002
CPT: 82105 Alpha Fetoprotein; serum
070.22-070.23 Chronic viral hepatitis B with hepatic coma, with or without mention of
hepatitis delta070.32-070.33 Chronic viral Hep B w/out mention of hepatic coma, with or w/out mention of
hepatitis delta070.44 Chronic hepatitis C with hepatic coma
070.54 Chronic hepatitis C without mention of hepatic coma
095.3 Syphilis of liver
121.1 Clonorchiasis
121.3 Fascioliasis
155.0-155.2 Malignant neoplasm of the liver and intrahepatic bile ducts
164.2-164.9 Malignant neoplasm of the mediastinum
183.0 Malignant neoplasm, ovary
186.0 Malignant neoplasm of undescended testis
186.9 Malignant neoplasm, other and unspecific testis
197.1 Secondary malignant neoplasm of mediastinum
197.7 Secondary malignant neoplasm of liver
198.6 Secondary malignant neoplasm of ovary
198.82 Secondary malignant neoplasm, genital organs
209.20-209.29 Malignant carcinoid tumors of other and unspecified sites
209.70 Secondary neuroendocrine tumor, unspecified site
209.71 Secondary neuroendocrine tumor of distant lymph nodes
209.72 Secondary neuroendocrine tumor of liver
209.73 Secondary neuroendocrine tumor of bone
209.74 Secondary neuroendocrine tumor of peritoneum
209.75 Secondary Merkel cell carcinoma
209.79 Secondary neuroendocrine tumor of other sites
211.5 Benign neoplasm of liver and biliary passages
235.3 Neoplasm of uncertain behavior of liver and biliary passages
272.2 Mixed hyperlipidemia
273.4 Alpha 1 antitrypsin deficiency
275.01 Hereditary hemochromatosis
275.02 Hemochromatosis due to repeated red blood cell transfusions
275.03 Other hemochromatosis
275.09 Other disorders of iron metabolism
275.1 Disorder of copper metabolism
277.00 Cystic Fibrosis without mention of meconium ileus
277.03 Cystic Fibrosis with gastrointestinal manifestations
277.6 Other deficiencies of circulating enzymes
285.0 Sideroblastic Anemia
338.3 Neoplasm related pain (acute) (chronic)
414.4 Coronary atherosclerosis due to calcified coronary lesion
444.01 Saddle embolus of abdominal aorta
444.09 Other arterial embolism and thrombosis of abdominal aorta
571.2 Alcoholic cirrhosis of liver
ALPHA FETO PROTEIN; SERUM
41 AFP (NCD)
National Coverage Decision November 25, 2002
ALPHA FETO PROTEIN; SERUM
571.40 Chronic hepatitis, unspecified
571.41 Chronic persistent hepatitis
571.42 Autoimmune hepatitis
571.49 Other chronic hepatitis
571.5 Cirrhosis of liver without mention of alcohol
573.5 Hepatopulmonary syndrome
608.89 Other specified disorders of male genital organs
793.11 Solitary pulmonary nodule
793.19 Other nonspecific abnormal finding of lung field
793.1 Non-specific abnormal findings of lung field
793.2 Non-specific abnormal findings of other intrathoracic organs
793.3 Non-specific abnormal findings of biliary tract
793.6 Non-specific abnormal findings of abdominal area, including retro peritoneum
795.89 Other abnormal tumor markers
V10.07 Personal history of malignant neoplasm, liver
V10.43 Personal history of malignant neoplasm, ovary
V10.47 Personal history of malignant neoplasm, testis
V86.0-V86.1 Estrogen receptor positive status [ER+]
Reviewed: April 2013
42 AFP (NCD)
National Coverage Decision November 25, 2002*THIS SECTION ONLY****ALL OTHER DIAGNOSIS WILL BE COVERED***
***LISTED BELOW ARE THE DIAGNOSES THAT ARE NOT COVERED***
CPT: 85004 Blood count automated differential white blood cell (WBC count
CPT: 85007 Blood count; manual differential WBC count (includes RBC morphology and
platelet estimation)CPT: 85008 Blood counts, manual blood smear examination without differential
parameters
CPT: 85013 Blood counts, Spun microhematocrit
CPT: 85014 Blood counts, Other than spun hematocrit
CPT: 85018 Blood counts, Hemoglobin
CPT: 85025 Hemogram and platelet count, automated and automated complete
differential WBC count (CBC)CPT: 85027 Blood counts, Hemogram and platelet count, automated
CPT: 85032 Manual cell count (erythrocyte, leukocyte, or platelet) each
CPT: 85048 Blood counts, White blood cell (WBC)
CPT: 85049 Platelet, automated
078.10-078.19 Viral Warts210.0-210.9 Benign neoplasm of lip, oral cavity, and pharynx214.0 Benign neoplasm of skin216.0-216.9 Benign neoplasm of skin 217 Benign neoplasm of breast222.0-222.9 Benign neoplasm of male genital organs224.0 Benign neoplasm of eyeball, except conjunctiva, cornea, retina, and choroid
230.0 Carcinoma in situ of lip, oral cavity and pharynx232.0-232.9 Carcinoma in situ of skin300.00-300.09 Neurotic disorders301.0-301.9 Personality disorders302.0-302.9 Sexual deviations and disorders307.0 Stammering 307.20-307.23 Tics307.3 Stereotyped movements disorder307.80-307.89 Pain disorders related to psychological factors312.00-312.9 Disturbance of conduct, not elsewhere classified313.0-313.9 Disturbance of emotions specific to childhood and adolescence314.00-314.9 Hyperkinetic syndrome of childhood338.0-338.4 Central pain syndrome363.30-363.35 Chorioretinal scars363.40-363.43 Choroidal degeneration363.50-363.57 Hereditary choroidal dystrophies363.70-363.9 Choroidal detachment366.00-366.9 Cataract367.0-367.9 Disorders of refraction and accommodation371.00-371.9 Corneal opacity and other disorders of cornea373.00-373.9 Inflammation of eyelids375.00-375.9 Disorders of lacrimal system376.21-376.9 Disorders of the orbit, except 376.3, other exophthalmic conditions377.10-377.16 Optic atrophy377.21-377.24 Other disorders of optic disc
BLOOD COUNTS
43 CBC (NCD)
National Coverage Decision November 25, 2002*THIS SECTION ONLY****ALL OTHER DIAGNOSIS WILL BE COVERED***
***LISTED BELOW ARE THE DIAGNOSES THAT ARE NOT COVERED***
BLOOD COUNTS
384.20-384.25 Perforation of tympanic membrane384.81-384.82 Other specified disorders of tympanic membrane385.00-385.9 Other disorders of middle ear and mastoid387.0-387.9 Otosclerosis388.00-388.5 Other disorders of ear389.00-389.9 Hearing Loss440.0-440.1 Atherosclerosis of aorta and renal artery443.81-443.9 Other and unspecified peripheral vascular disease
448.1 Capillary nevus, non neoplastic457.0 Postmastectomy lymphedema syndrome470 Deviated nasal septum
471.0-471.9 Nasal polyps478.0 Hypertrophy of nasal turbinates478.4 Polyp of vocal cord or larynx478.11, 478.19 Nasal mucositis (ulcerative)478.19 Other disease of nasal cavity and sinuses520.0-520.9 Disorders of tooth development and eruption521.00-521.9 Diseases of hard tissues of teeth524.00-524.9 Dentofacial anomalies, including malocculsion525.0-525.9 Other diseases and conditions of teeth and supporting structures526.0-526.3 Diseases of the jaws527.6-527.9 Disease of salivary glands575.6 Cholesterolosis of gallbladder600.00-600.91 Hyperplasia of prostate603.0 Encysted hydrocele603.8 Other specified types of hydrocele603.9 Hydrocele, unspecified
605 Redundant prepuce and phimosis606.0-606.1 Infertility, male azoospermia and oligospremia
608.1 Spermatocoele608.3 Atrophy of testis608.20-608.24 Torsion of testis610.0-610.9 Benign mammary dysplasia611.1-611.6 Other disorders of breast611.9 Unspecified breast disorder616.2 Cyst of Bartholin's gland618.00-618.9 Genital prolapse620.0-620.3 Noninflammatory disorders of ovary, fallopian tube, and broad ligament
621.6-621.7 Malposition or chronic inversion of uterus
627.2-627.9 Menopausal and post menopausal disorders628.0-628.9 Infertility, female676.00-676.94 Other disorders of breast associated with childbirth and disorders of lactation
691.0-691.8 Atopic dermatitis and related disorders692.0-692.9 Contact dermatitis and other eczema700 Corns and callosities701.0-701.9 Other hypertrophic and atrophic conditions of skin702.0-702.8 Other dermatoses703.9 Unspecified disease of nail706.0-706.9 Diseases of sebaceous glands
44 CBC (NCD)
National Coverage Decision November 25, 2002*THIS SECTION ONLY****ALL OTHER DIAGNOSIS WILL BE COVERED***
***LISTED BELOW ARE THE DIAGNOSES THAT ARE NOT COVERED***
BLOOD COUNTS
709.00-709.4 Other disorders of skin and subcutaneous tissue715.00-715.98 Osteoarthrosis716.00-716.99 Other and unspecified arthropathies718.00-718.99 Other derangement of joint726.0-726.91 Peripheral esthesiopathies and allied syndromes727.00-727.9 Other disorders of synovium, tendon, and bursa728.10-728.85 Disorders of muscle ligament and fascia732.0-732.9 Osteochondropathies733.00-733.09 Osteoporosis734 Flat foot
735.0-735.9 Acquired deformities of toe
736.00-736.9 Other acquired deformities of limb737.0-737.9 Curvature of spine738.0-738.9 Other acquired deformity739.0-739.9 Nonallopathic lesions, not elsewhere classified
799.81 Decreased libido830.0-832.19 Dislocation of jaw, shoulder, and elbow832.2 Nursemaid's elbow833.00-833.19 Dislocation of wrist834.00-834.12 Dislocation of finger835.00-835.13 Dislocation of hip836.0-836.69 Dislocation of knee837.0-837.1 Dislocation of ankle838.00-838.19 Dislocation of foot839.00-839.9 Other, multiple and ill-defined dislocations840.0-848.9 Sprains and strains of joints and adjacent muscles905.0-909.9 Late effects of musculoskeletal and connective tissue injuries910.0-919.9 Superficial injuries930.0-932 Foreign body on external eye, in ear, in nose955.0-957.9 Injury to peripheral nerveV03.0-V06.9 Need for prophylactic vaccinationV11.0-V11.3 Personal history of mental disorder; schizophrenia, affective disorders,
neurosis, and alcoholismV11.4 Personal history of combat and operational stress reactionV11.8-V11.9 Personal history of other and unspecified mental disordersV14.0-V14.8 Personal history of allergy to medicinal agentsV16.0 Family history of malignant neoplasm, gastrointestinal tractV16.3 Family history of malignant neoplasm, breastV16.52 Family history of malignant neoplasm, bladderV21.0-V21.9 Consitutional states in developmentV25.01-V25.04, V25.9 Encounter for contraceptive management
V25.11 Encounter for insertion of intrauterine contraceptive deviceV25.12 Encounter for removal of intrauterine contraceptive deviceV25.13 Encounter for removal and reinsertion of intrauterine contraceptive device
V25.2-V25.3, V25.40-
V25.43, V25.49, V25.5,
V25.8, V25.9
Encounter for sterilization; menstrual extraction; surveillance of previously
prescribed contraceptive methods; and insertion of implantable subdermal
contraceptive; other specified and unspecified contraceptive management
V26.0-V26.9 Procreative management
45 CBC (NCD)
National Coverage Decision November 25, 2002*THIS SECTION ONLY****ALL OTHER DIAGNOSIS WILL BE COVERED***
***LISTED BELOW ARE THE DIAGNOSES THAT ARE NOT COVERED***
BLOOD COUNTS
V40.0-V40.9 Mental and behavioral problemsV41.0-V41.9 Problems with special senses and other special functionsV43.0-V43.1 Organ or tissue replaced by other means, eye globe or lensV44.0-V44.9 Artificial opening statusV45.00-V45.89 Other post surgical statesV48.0-V48.9 Problems with head, neck and trunkV49.0-V49.85 Other conditions influencing health statusV49.86 Do not resuscitate statusV49.87 Physical restraints statusV49.89-V49.9 Other specified and unspecified conditions influencing health statusV51.0 Encounter for breast reconstruction following mastectomyV51.8 Other aftercare involving the use of plastic surgeryV52.0-V52.9 Fitting and adjustment of prosthetic device and implantV53.01-V53.09 Fitting and adjustment of devices related to nervous system and special
sensesV53.1 Fitting and adjustment of spectacles and contact lenses
V53.31-V53.39 Fitting and adjustment of cardiac device
V53.4 Fitting and adjustment of orthodontic devices
V53.50 Fitting and adjustment of intestinal appliance or deviceV53.51 Fitting and adjustment of gastric lap bandV53.59 Fitting and adjustment of other gastrointestinal appliance and deviceV53.5 Fitting and adjustment of other intestinal appliance
V53.6 Fitting and adjustment of urinary devicesV53.7 Fitting and adjustment of orthopedic devicesV53.8 Fitting and adjustment of wheelchairV53.90-V53.99 Fitting and adjustment of other and unspecified deviceV54.01-V54.9 Other orthopedic aftercareV55.0-V55.9 Attention to artificial openingsV57.0-V57.9 Care involving use of rehabilitation proceduresV58.5 OrthodonticsV59.01-V59.9 DonorsV61.0-V61.09 Other family circumstancesV61.09 Other family disruption V61.10 Counseling for marital and partner problems, unspecifiedV61.12 Counseling for perpetrator of spousal and partner abuse V61.20 Counseling for parent-child problem V61.21 Counseling for victim of child abuseV61.22 Counseling for perpetrator of parental child abuse
V61.23 Counseling for parent-biological child problemV61.24 Counseling for parent-adopted child problemV61.25 Counseling for parent (guardian)-foster child problemV61.29 Other parent-child problems (Description Revised 10/09)V61.3 Problems with aged parents or in-lawsV61.41 Alcoholism in familyV61.42 Substance abuse in familyV61.49, V61.5-V61.9 Other specified and unspecified family problemsV62.21 Personal current military deployment status
V62.22 Personal history of return from military deploymentV62.29 Other occupational circumstances or maladjustment
46 CBC (NCD)
National Coverage Decision November 25, 2002*THIS SECTION ONLY****ALL OTHER DIAGNOSIS WILL BE COVERED***
***LISTED BELOW ARE THE DIAGNOSES THAT ARE NOT COVERED***
BLOOD COUNTS
V62.3-V62.84 Educational circumstances; other psychological or physical stress, not
elsewhere classified; suicidal ideation
V62.85 Homicidal ideation
V62.89-V62.9 Other psychological or physical stress, not elsewhere classified; and
unspecified psychosocial circumstances
V65.2 Person feigning illness
V65.3 Dietary surveillance and counseling
V65.40-V65.49 Other counseling, not elsewhere classifiedV65.5 Person with feared complaint in whom no diagnosis was madeV65.8 Other reasons for seeking consultationV65.9 Unspecified reason for consultationV66.0-V66.9 Convalescence and palliative careV67.3 Follow-up examination following psychotherapyV67.4 Follow-up examination following treatment of healed fractureV69.3 Problems related to lifestyle, gambling and betting
V70.0 Routine general examinationV71.01-V71.09 Observation and evaluation for suspected conditions not found, mentalV72.0-V72.2 Special investigations, examination of eyes and vision, ears and hearing,
dentalV72.40-V72.7 Special investigations, pregnancy exam, radiologic exam, laboratory exam,
diagnostic skin and sensitization testsV72.9 Special investigation, unspecifiedV73.81 Special screening exam for Human papillomavirus (HPV)V76.10-V76.19 Special screening for malignant neoplasms, breastV76.2 Special screening for malignant neoplasms, cervixV76.44 Special screening for malignant neoplasms, prostateV76.51 Special screening for malignant neoplasms. Intestine, colonV77.1 Special screening for diabetes mellitusV81.0-V81.2 Special screening for cardiovascular disease
Reviewed: April 2013
47 CBC (NCD)
Medicare A Medical Policy September 21, 2010
CPT: 83880 Natriuretic peptide
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-IV, or unspecified404.03 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-IV, or unspecified404.13 Hypertensive heart and chronic kidney disease, benign, with heart failure and
with 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-IV, or unspecified
404.93 Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and with chronic kidney disease stage V or End Stage Renal Disease
410.62 True posterior wall infarction subsequent episode of care
410.72 Subendocardial infarction subsequent episode of care
410.82 Acute myocardial infarction of other specified sites subsequent episode of
care410.92 Acute myocardial infarction of unspecified site subsequent episode of care
423.2 Constrictive pericarditis
425.4 Other primary cardiomyopathies
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
519.11 Acute bronchospasm
786.00 Respiratory abnormality unspecified
786.02 Orthopnea
786.05 Shortness of breath
B-TYPE NATRIURETIC PEPTIDE (BNP)
48 BNP (LCD)
Medicare A Medical Policy September 21, 2010
B-TYPE NATRIURETIC PEPTIDE (BNP)
786.06 Tachypnea
786.07 Wheezing
786.09 Respiratory abnormality other
Reviewed: April 2013
49 BNP (LCD)
National Coverage Decision November 25, 2002
CPT: 86304 Immunoassay for tumor antigen, quantitative, CA125
158.8-158.9 Malignant neoplasms, peritoneum, unspecified
180.0 Malignant neoplasm, endocervix
182.0 Malignant neoplasm of corpus uteri, except isthmus
183.0 Malignant neoplasm, ovary
183.2 Malignant neoplasm, fallopian tube
183.8 Malignant neoplasm, other specified sites of uterine adnexa
184.8 Malignant neoplasm, other specified sites of female genital organs
198.6 Secondary malignant neoplasm, ovary
198.82 Secondary malignancy of genital organs
236.0-236.3 Neoplasm of uncertain behavior of female genital organs
338.3 Neoplasm related pain (acute)(chronic)
789.39 Abdominal or pelvic swelling, mass, or lump, other specified site
795.82 Elevated cancer antigen 125 (CA 125)
795.89 Other abnormal tumor markers
V10.41-V10.42 Personal history of malignant neoplasm, other parts of uterus
V10.43-V10.44 Personal history of malignant neoplasm of female genital organs
Reviewed: April 2013
CA125
50 CA 125 (NCD)
National Coverage Decision November 25, 2002
CPT: 86300 Immunoassay for tumor antigen, quantitative, CA15-3 / CA 27.29
174.0-174.9 Breast, primary (female) - malignant neoplasm of female breast
175.0-175.9 Breast, primary (male) - malignant neoplasm of male breast
198.2 Secondary malignant neoplasm (breast)
198.81 Secondary malignant neoplasm (breast)
338.3 Neoplasm related pain (acute)(chronic)
795.89 Other abnormal tumor markers
V10.3 Personal history of malignant neoplasm, breast
Reviewed: April 2013
CA 15-3 / CA 27.29
51 CA 15-3 / CA 27.29 (NCD)
National Coverage Decision November 25, 2002
CPT: 86301 Immunoassay for tumor antigen, quantitative, CA19-9
155.1 Malignant neoplasm, intrahepatic bile ducts
156.0 Malignant neoplasm, gallbladder
156.1 Malignant neoplasm, extrahepatic bile ducts
156.2 Malignant neoplasm, ampulla of Vater
156.8 Malignant neoplasm, other specified sites of gallbladder and extrahepatic bile
ducts
156.9 Malignant neoplasm, unspecified part of biliary tract
157.0-157.9 Malignant neoplasm, pancreas
197.8 Secondary malignant neoplasm, other digestive organs and spleen
235.3 Neoplasm of uncertain behavior, liver and biliary passages
235.5 Neoplasm of uncertain behavior, other and unspecified digestive organs
338.3 Neoplasm related pain (acute)(chronic)
795.89 Other abnormal tumor markers
V10.09 Other personal history of cancer
Reviewed: April 2013
CA 19-9
52 CA 19-9 (NCD)
National Coverage Decision November 25, 2002
CPT: 82378 Carcinoembryonic Antigen
150.0-150.9 Malignant neoplasm of the esophagus
151.0-151.9 Malignant neoplasm of stomach
152.0-154.8 Malignant neoplasm of small intestine, including duodenum, rectum,
157.0-157.9 Primary malignancy of pancreas
159.0 Malignant neoplasm of intestinal tract, part unspecified
162.0-162.9 Malignant neoplasm of trachea, bronchus, lung
174.0-174.9 Malignant neoplasm of female breast
175.0-175.9 Malignant neoplasm of male breast
183.0 Malignant neoplasm of ovary
197.0 Secondary malignant neoplasm of lung
197.4 Secondary malignant neoplasm of small intestine
197.5 Secondary malignant neoplasm of large intestine and rectum
209.00-209.03 Malignant carcinoid tumors of the small intestine
209.10-209.17 Malignant carcinoid tumors of the appendix, large intestine and rectum
209.20-209.29 Malignant carcinoid tumors of other and unspecified sites
209.70 Secondary neuroendocrine tumor, unspecified site
209.71 Secondary neuroendocrine tumor of distant lymph nodes
209.72 Secondary neuroendocrine tumor of liver
209.73 Secondary neuroendocrine tumor of bone
209.74 Secondary neuroendocrine tumor of peritoneum
209.75 Secondary Merkel cell carcinoma
209.79 Secondary neuroendocrine tumor of other sites
230.3 Carcinoma in situ of colon
230.4 Carcinoma in situ of rectum
230.7 Carcinoma in situ of other/unspecified parts of intestine
230.9 Carcinoma in situ other and unspecified digestive organs
235.2 Neoplasm of uncertain behavior of stomach, intestines, rectum
338.3 Neoplasm related pain (acute) (chronic)
790.99 Other nonspecific findings on examination of blood
795.81 Elevated Carcinoembryonic Antigen (CEA)
795.89 Other abnormal tumor markers
V10.00 Personal history of malignant neoplasm of gastro-intestinal tract, unspecified
V10.05 Personal history of malignant neoplasm, large intestine
V10.06 Personal history of malignant neoplasm, rectum, rectosigmoid junction, anus
V10.11 Personal history of malignant neoplasm, bronchus, and lung
V10.3 Personal history of malignant neoplasm, breast
V10.43 Personal history of malignant neoplasm, ovary
V67.2 Follow-up examination following chemotherapy
Reviewed: April 2013
CARCINOEMBRYONIC ANTIGEN (CEA)
53 CEA (NCD)
National Coverage Decision November 25, 2002
CPT: 82523 Collagen cross links, any method
242.00-242.91 Thyrotoxicosis
245.2 Chronic lymphocytic thyroiditis (only if thyrotoxic)
246.9 Unspecified disorder of thyroid
252.00-252.02 Hyperparathyroidism
252.08 Hyperparathyroidism
256.2 Postablative ovarian failure
256.31-256.39 Other ovarian failure
256.8 Other ovarian dysfunction
256.9 Unspecified ovarian dysfunction
268.9 Unspecified vitamin D deficiency
269.3 Mineral deficiency, not elsewhere classified
627.0 Premenopausal menorrhagia
627.1 Postmenopausal bleeding
627.2 Menopausal or female climacteric state
627.4 States associated with artificial menopause
627.8 Other specified menopausal and postmenopausal disorders
627.9 Unspecified menopausal & postmenopausal disorder
731.0 Osteitis deformans without mention of bone tumor (Paget's disease of bone)
733.00-733.09 Osteoporosis
733.10-733.19 Pathological fracture
733.90 Disorder of bone and cartilage, unspecified
805.8 Fracture of vertebral column without mention of spiral cord injury,
unspecified, closed V58.65 Long-term (current) use of steroids
V58.69 Long-term (current) use of other medications
Reviewed: April 2013
COLLAGEN CROSS LINKS (NTX)
54
COLLAGEN CROSS LINKS
NTX (NCD)
National Coverage Decision November 25, 2002
CPT: 80162 Digoxin
242.00-242.91 Thyrotoxicosis with or without goiter
243 Congenital hypothyroidism
244.0-244.9 Acquired hypothyroidism
245.0-245.9 Thyroiditis
275.2 Disorders of magnesium metabolism
275.40-275.49 Disorders of calcium metabolism
275.5 Hungry bone syndrome
276.0 Hyperosmolality
276.1 Hyposmolality
276.2 Acidosis
276.3 Alkalosis
276.4 Mixed acid-base balance disorder
276.50-276.52 Volume depletion
276.61 Transfusion associated circulatory overload
276.69 Other fluid overload
276.7 Hyperpotassemia
276.8 Hypopotassemia
276.9 Electrolyte and fluid Disorder (not elsewhere classified)
293.0 Acute delirium
293.1 Subacute delirium
307.47 Other dysfunctions of sleep stages or arousal from sleep
339.3 Drug induced headache, not elsewhere classified
368.16 Psychopysical visual disturbances
368.8 Other specified visual disturbances
368.9 Unspecified visual disturbances
397.9 Rheumatic diseases of endocardium
398.0 Rheumatic Myocarditis
398.91 Rheumatic Hearth Failure
402.01 Hypertensive heart disease, malignant with CHF
402.11 Hypertensive heart disease, benign with CHF
402.91 Hypertensive heart disease, unspecified with CHF
403.00-403.91 Hypertensive renal disease
404.00-404.93 Hypertensive heart and renal disease
410.00-410.92 Acute myocardial infarction
411.0-411.89 Other acute and subacute forms of ischemic heart disease
413.0-413.9 Angina pectoris
414.4 Coronary atherosclerosis due to calcified coronary lesion
422.0-422.99 Acute myocarditis
425.0, 425.11, 425.18
425.2-425.9Cardiomyopathy
DIGOXIN THERAPEUTIC DRUG ASSAY (ANY SOURCE)
55 DIGOXIN (NCD)
National Coverage Decision November 25, 2002
DIGOXIN THERAPEUTIC DRUG ASSAY (ANY SOURCE)
426.0-426.9 Conduction disorders
427.0-427.9 Cardiac dysrhythmias
428.0-428.9 Heart failure
429.2 Cardiovascular disease, unspecified
429.4 Heart Disturbances Postcardiac Surgery
429.5 Rupture chordae tenineae
429.6 Rupture papillary muscle
429.71 Acquired cardiac septal defect
444.01 Saddle embolus of abdominal aorta
444.09 Other arterial embolism and thrombosis of abdominal aorta
514 Pulmonary congestion and hypostasis
573.5 Hepatopulmonary syndrome
579.9 Unspecified intestinal malabsorption
584.5-584.9 Acute renal failure
585.1-585.9 Chronic renal failure
586 Renal Failure, unspecified
587 Renal sclerosis, unspecified
588.0 Renal osteodystrophy
588.1 Nephrogenic Diabetes Insipidus
588.81, 588.89 Impaired renal function (not elsewhere classified)
588.9 Unspecified disorder resulting from impaired renal function
780.01 Coma
780.02 Transient alteration of awareness
780.09 Other ill-defined general symptoms (drowsiness, semicoma, somnolence,
stupor, unconsciousness)
780.1 Hallucinations
780.2 Syncope & collapse
780.4 Dizziness and giddiness
780.71-780.79 Malaise and fatigue
783.0 Anorexia
784.0 Headache
787.01-787.03 Nausea and vomiting
787.04 Bilious emesis
787.91 Diarrhea
794.31 Abnormal electrocardiogram
799.21 Nervousness
799.22 Irritability
799.23 Impulsiveness
799.24 Emotional lability
799.25 Demoralization and apathy
799.29 Other signs and symptoms involving emotional state
56 DIGOXIN (NCD)
National Coverage Decision November 25, 2002
DIGOXIN THERAPEUTIC DRUG ASSAY (ANY SOURCE)
972.0 Poisoning by cardiac rhythm regulators
972.1 Poisoning by cardiotonic glycosides and drugs of similar action
995.20 Unspecified adverse effect of unspecified drug, medicinal and biological
995.21 Arthus phenomenon
995.24 Failed moderate sedation during procedure
995.27 Other drug allergy
995.29 Unspecified adverse effect of other drug, medicinal and biological substance
**E942.1 Adverse effect of cardiotonic glycosides and drugs of similar action
V58.69 Encounter long term medication use (not elsewhere classified)
** Code may not be reported as a stand-alone or first-listed code on the claim.
Reviewed: April 2013
57 DIGOXIN (NCD)
National Coverage Decision November 25, 2002
CPT: 82977 Glutamyltransferase, gamma (GGT)
003.1 Salmonella septicemia
006.0-006.9 Amebiasis
014.00-014.86 Tuberculosis of intestines, peritoneum, and mesenteric glands
017.90-017.96 Tuberculosis of other organs
018.90-018.96 Miliary tuberculosis, unspecified
020.0-020.9 Plague
022.3 Anthrax septicemia
027.0 Listeriosis
027.1 Erysipelothrix infection
030.1 Tuberculoid leprosy (Type T)
032.83 Diptheritic peritonitis
036.1 Meningococcal encephalitis036.2 Meningococcemia038.0-038.9 Septicemia039.2 Actinomycotic infections, abdominal040.0 Gas gangrene042 Human immunodeficiency virus (HIV) disease054.0 Eczema herpeticum054.5 Herpetic septicemia060.0-060.1 Yellow fever070.0-070.9 Viral hepatitis072.71 Mumps073.0 Ornithosis, with pneumonia074.8 Specific diseases due to Coxsackie virus075 Infectious mononucleosis078.5 Other diseases due to viruses and Chlamydiae079.99 Unspecified viral infection082.0-082.9 Tick-borne rickettsioses, stet084.9 Malaria086.1 Chagas disease with organ involvement other than heart088.81 Lyme disease091.62 Secondary syphilitic hepatitis095.3 Syphilis of liver100.0 Leptospirosis icterohemorrhagica112.5 Candidiasis, disseminated115.00 Infection by Histoplasm capsulatum without mention of manifestation120.9 Schistosomiasis, unspecified121.1 Clonorchiasis121.3 Fascioliasis122.0 Echinococcus granulosus infection of liver122.5 Echinococcus multilocularis infection of liver122.8 Echinococcosis, unspecified, of liver122.9 Echinococcus, other and unspecified130.5 Hepatitis due to toxoplasmosis 135 Sarcoidosis150.0-159.9 Malignant neoplasm of digestive organs and peritoneum160.0-165.9 Malignant neoplasm of respiratory and intrathoracic organs170.0-176.9 Malignant neoplasm of bone, connective tissue, skin, and breast
GAMMA GLUTAMYLTRANSFERASE (GGT)
58 GGT (NCD)
National Coverage Decision November 25, 2002
GAMMA GLUTAMYLTRANSFERASE (GGT)
179-189.9 Malignant neoplasm of genitourinary organs200.00-208.92 Malignant neoplasm of lymphatic and hematopoietic tissue209.20-209.29 Malignant carcinoid tumors of other and unspecified sites209.70 Secondary neuroendocrine tumor, unspecified site209.71 Secondary neuroendocrine tumor of distant lymph nodes209.72 Secondary neuroendocrine tumor of liver209.73 Secondary neuroendocrine tumor of bone209.74 Secondary neuroendocrine tumor of peritoneum209.75 Secondary Merkel cell carcinoma209.79 Secondary neuroendocrine tumor of other sites211.5 Benign neoplasm of liver and biliary passages211.6 Benign neoplasm of pancreas, except islets of Langerhans211.7 Benign neoplasm of islets of Langerhans228.04 Hemangioma of intrac-abdominal structures230.7 Carcinoma in situ of other and unspecified parts of intestine 230.8 Carcinoma in situ of liver and biliary system230.9 Carcinoma in situ other and unspecified digestive organs235.0-235.9 Neoplasms of uncertain behavior of digestive and respiratory systems236.0-236.99 Neoplasms of uncertain behavior of genitourinary organs237.73 Schwannomatosis237.79 Other neurofibromatosis237.9 Neoplasms of uncertain behavior of other and uncertain parts of the nervous
system
238.0-238.6 Neoplasms of uncertain behavior of other and unspecified sites and tissues
238.71-238.76 Neoplasms of other lymphatic and hematopoietic tissues238.77 Post-transplant lymphoproliferative disorder (PTLD)238.79 Neoplasm of uncertain behavior 238.8 Neoplasms of uncertain behavior of other specified sites238.9 Neoplasms of uncertain behavior of unspecified sites239.0 Neoplasm of unspecified nature of digestive system250.00-250.93 Diabetes mellitus252.00-252.02, 252.08 Hyperparathyroidism
263.1 Malnutrition of mild degree263.9 Unspecified protein-calorie malnutrition268.0 Rickets, active268.2 Osteomalacia, unspecified269.0 Deficiency of vitamin K270.2 Other disturbances of aromatic amino acid metabolism270.9 Unspecified disorder of amino acid metabolism271.0 Glycogenosis272.0 Pure hypercholesterolemia272.1 Pure hyperglyceridemia272.2 Mixed hyperlipidemia272.4 Other and unspecified hyperlipidemia272.7 Lipidoses272.9 Unspecified disorder of lipoid metabolism273.4 Alpha 1 antitrypsin deficiency275.01 Hereditary hemochromatosis275.02 Hemochromatosis due to repeated red blood cell transfusions275.03 Other hemochromatosis275.09 Other disorders of iron metabolism275.1 Disorders of copper metabolism
59 GGT (NCD)
National Coverage Decision November 25, 2002
GAMMA GLUTAMYLTRANSFERASE (GGT)
275.2 Disorders of magnesium metabolism275.3 Disorders of phosphorus metabolism275.40-275.49 Disorders of calcium metabolism275.5 Hungry bone syndrome277.1 Disorders of porphyrin metabolism277.30-277.31, 277.39 Amyloidosis
277.4 Disorders of bilirubin excretion277.6 Other deficiencies of circulating enzymes282.60-282.69 Sickle cell anemia286.6 Defibrination syndrome286.7 Acquired coagulation factor deficiency
289.4 Hypersplenism289.52 Splenic sequestration291.0-291.9 Alcoholic psychoses303.00-303.03 Acute alcoholic intoxication303.90-303.93 Other and unspecified alcohol dependence304.00-304.93 Drug dependence305.00-305.93 Non-dependent abuse of drugs357.5 Alcoholic polyneuropathy359.21-359.29 Myotonic disorders452 Portal vein thrombosis453.0-453.9 Other vein embolism and thrombosis456.0-456.21 Esophageal varices555.0-555.9 Regional enteritis556.0-556.9 Ulcerative colitis557.0 Acute vascular insufficiency of intestine
558.1-558.9 Other noninfectious gastroenteritis and colitis560.0-560.2 Intestinal obstruction: intussusceptions, paralytic ileus, volvulus560.3 Impaction of intestine, unspecified560.31 Gallstone ileus560.32 Fecal impaction560.39 Other impaction of intestine560.81-560.89, 560.9 Other and unspecified intestinal obstruction562.01 Diverticulitis of small intestine (without mention of hemorrhage)562.03 Diverticulitis of small intestine with hemorrhage562.11 Diverticulitis of colon (without mention of hemorrhage)562.13 Diverticulitis of colon with hemorrhage567.0-567.9 Peritonitis569.83 Perforation of intestine569.87 Vomiting of fecal matter570 Acute and subacute necrosis of liver571.0-571.9 Chronic liver disease and cirrhosis572.0-572.8 Liver abscess and sequelae of chronic liver disease573.0-573.9 Other disorders of liver574.00-574.91 Cholelithiasis575.0-575.9 Other disorders of gallbladder576.0-576.9 Other disorders of biliary tract581.0-581.9 Nephrotic syndrome
582.0-582.9 Chronic glomerulonephritis583.0-583.9 Nephritis and nephropathy not specified as acute or chronic584.5-584.9 Acute renal failure585.6 Chronic renal failure
60 GGT (NCD)
National Coverage Decision November 25, 2002
GAMMA GLUTAMYLTRANSFERASE (GGT)
586 Renal failure, unspecified587 Renal sclerosis, unspecified588.0-588.9 Disorders resulting from impaired renal function590.00-590.9 Infections of kidney642.50-642.54 Severe pre-eclampsia646.70,646.71,646.73 Liver disorders in pregnancy782.4 Jaundice, unspecified, not of newborn789.1 Hepatomegaly790.4 Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase
790.5 Other nonspecific abnormal serum enzyme levels
960.00-969.09 Poisoning by antidepressants969.70-969.79 Poisoning by psychostimulants969.8, 969.9 Poisoning by other specified and unspecified psychotropic agents970.0-970.1 Poisoning by analeptics and opiate antagonists
970.81 Poisoning by cocaine970.89 Poisoning by other central nervous system stimulants970.9 Poisoning by unspecified central nervous system stimulants971.0-971.3, 971.9 Poisoning by drugs primarily affecting the autonomic nervous system972.0-972.9 Poisoning by agents primarily affecting the cardiovascular system973.0-973.6, 973.8,
973.9
Poisoning by agents primarily affecting the GI system
974.0-974.7 Poisoning by water, mineral, and uric acid metabolism drugs975.0-975.8 Poisoning by agents primarily acting on the smooth and skeletal muscles and
respiratory system976.0-976.9 Poisoning by agents primarily affecting skin and mucous membrane,
ophthalmological, otorhinolaryngological, and dental drugs977.0-977.4, 977.8,
977.9
Poisoning by other and unspecified drugs, and medicinal substances
978.0-978.6, 978.8,
978.9
Poisoning by bacterial vaccines
979.0-979.7 Poisoning by other vaccines and biological substances979.9 Poisoning by drugs, medicinal, and biological substances980.0-989.89 Toxic effects of substances chiefly nonmedicinal as to sourceV42.7 Organ replaced by transplant, liverV58.61-V58.69 Long Term (current) drug useV67.1 Follow up examination, radiotherapyV67.2 Follow up examination, chemotherapyV67.51 Follow up examination after completed treatment with high-risk medications,
not elsewhere classified
Reviewed: April 2013
61 GGT (NCD)
National Coverage Decision November 25, 2002
CPT: 82985 Glycated protein
CPT: 83036 Hemoglobin; Glycated
211.7 Benign neoplasm of islets of Langerhans
249.00-249.91 Secondary Diabetes Mellitus, with or without various manifestations
250.00-250.93* Diabetes mellitus & various related codes
251.0 Hypoglycemic coma
251.1 Other specified hypoglycemia
251.2 Hypoglycemia unspecified
251.3 Post-surgical hypoinsulinemia
251.4 Abnormality of secretion of glucagon
251.8 Other specified disorders of pancreatic internal secretion
251.9 Unspecified disorder of pancreatic internal secretion
258.0-258.9 Polyglandular dysfunction271.4 Renal glycosuria275.01 Hereditary hemochromatosis275.02 Hemochromatosis due to repeated red blood cell transfusions275.03 Other hemochromatosis275.09 Other disorders of iron metabolism
577.1 Chronic pancreatitis579.3 Other and unspecified postsurgical nonabsorption648.00* Diabetes mellitus complicating pregnancy, childbirth or the puerperium,
unspecified as to episode of care or not applicable
648.03* Diabetes mellitus complicating pregnancy, Childbirth or the puerperium,
antepartum condition or complication
648.04* Diabetes mellitus complicating pregnancy, childbirth or the puerperium,
postpartum condition or complication
648.80 Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, unspecified as to episode of care or not applicable648.83 Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, antepartum condition or complication648.84 Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, postpartum condition or complication790.21 Impaired fasting glucose
790.22 Impaired glucose tolerance test790.29 Other abnormal glucose (hyperglycemia)790.6 Other abnormal blood chemistry962.3 Poisoning by insulin and antidiabetic agentsV12.21 Personal history of gestational diabetesV12.29 Personal history of other endocrine, metabolic, and immunity disordersV58.67 Long-term use of insulinV58.69 Long-term use of other medication
GLYCATED HEMOGLOBIN AND GLYCATED PROTEIN
Frequency Limitation: This test is only deemed medically necessary every 3 months.
62 GLHGB (NCD)
National Coverage Decision November 25, 2002
GLYCATED HEMOGLOBIN AND GLYCATED PROTEIN
Reviewed: April 2013
* Per Medicare, www.cms.gov, it is not considered reasonable and necessary to perform glycated
hemoglobin tests more often than every three months on a controlled diabetic patient to determine
whether the patient's metabolic control has been on average within the target range. It is not
considered reasonable and necessary for these tests to be performed more frequently than once a
month for diabetic pregnant women. Testing for uncontrolled type one or two diabetes mellitus may
require testing more than four times a year. Refer to CMS guidelines for the clinical basis for those
situations in which testing more frequently than four times per annum is indicated. Medical
necessity documentation must support such testing in excess of the above guidelines.
63 GLHGB (NCD)
National Coverage Decision November 25, 2002
CPT: 82947 Glucose; quantitative, blood (except reagent strip)CPT: 82948 Glucose; blood, reagent stripCPT: 82962 Glucose, blood by glucose monitoring device(s) cleared by the FDA
specifically for home use
011.00-011.96 Tuberculosis038.0-038.9 Septicemia112.1 Recurrent vaginal candidiasis112.3 Interdigital candidiasis118 Opportunistic mycoses157.4 Malignant neoplasm of Islets of Langerhans158.0 Malignant neoplasm of retroperitoneum211.7 Benign neoplasm of Islets of Langerhans242.00-242.91 Thyrotoxicosis249.00-249.91 Secondary Diabetes Mellitus, with or without various manifestations250.00-250.93 Diabetes mellitus251.0-251.9 Disorders of pancreatic internal secretion253.0-253.9 Disorders of the pituitary gland 255.0 Cushing syndrome263.0-263.9 Malnutrition271.0-271.9 Disorders of carbohyrdate transport and metabolism272.0-272.4 Disorders of lipoid metabolism275.01 Hereditary hemochromatosis275.02 Hemochromatosis due to repeated red blood cell transfusions275.03 Other hemochromatosis275.09 Other disorders of iron metabolism276.0 Hyperosmolality and/or hypernatremia276.1 Hyposmolality and/or hyponatremia276.2 Acidosis276.3 Alkalosis276.4 Mixed Aacid-base balance disorder276.50 Volume depletion, unspecified276.51 Dehydration276.52 Hypovolemia276.61 Transfusion associated circulatory overload276.69 Other fluid overload276.7 Hyperpotassemia276.8 Hypopotassemia276.9 Electrolyte and fluid disorders not elsewhere classified278.3 Hypercarotinemia293.0 Acute delirium294.9 Unspecified organic brain syndrome298.9 Unspecified psychosis300.9 Unspecified neurotic disorder310.1 Organic personality syndrome331.83 Mild cognitive impairment, so stated337.9 Autonomic nervous system neuropathy345.10-345.11 Generalized convulsive epilepsy 348.31 Encephalopathy, unspecified355.9 Neuropathy, not otherwise specified
GLUCOSE TESTING (BLOOD)
Frequency Limitation: See "Frequency Test List" for specifics.
64 GLUCOSE (NCD)
National Coverage Decision November 25, 2002
GLUCOSE TESTING (BLOOD)
356.9 Unspecified hereditary and idiopathic peripheral neuropathy357.9 Unspecified inflammatory and toxic neuropathy362.10 Background retinopathy362.18 Retinal vasculitis362.29 Nondiabetic proliferative retinopathy362.50-362.57 Degeneration of macular posterior pole362.60-362.66 Peripheral retinal degeneration362.81-382.89 Other retinal disorders362.9 Unspecified retinal disorders365.04 Borderline glaucoma, ocular hypertension365.32 Corticosteroid-induced glaucoma residual366.00-366.09 Presenile cataract366.10-366.19 Senile cataract367.1 Acute myopia368.8 Other specified visual disturbance373.00 Blepharitis377.24 Pseudopapilledema377.9 Unspecified disorder of optic nerve and visual pathways378.50-378.55 Paralytic strabismus379.45 Argyll-Robertson pupils410.00-410.92 Acute myocardial infarctions414.00-414.19 Coronary atherosclerosis and aneurysm of heart414.3 Coronary atherosclerosis due to lipid rich plaque414.4 Coronary atherosclerosis due to calcified coronary lesion425.9 Secondary cardiomyopathy, unspecified440.23 Arteriosclerosis of extremities with ulceration440.24 Arteriosclerosis of extremities with gangrene440.9 Arteriosclerosis, not otherwise specified458.0 Postural hypotension462 Acute pharyngitis466.0 Acute bronchitis480.0-486 Pneumonia490 Recurrent bronchitis, not specified as acute or chronic491.0-491.9 Chronic bronchitis527.7 Disturbance of slaivary secretion (drymouth)528.00, 528.09 Stomatitis535.50-535.51 Gastritis536.8 Dyspepsia571.8 Other chronic nonalcoholic liver disease572.0-572.8 Liver abscess and sequelae of chronic liver disease574.50-574.51 Choledocholithiasis575.0-575.12 Cholecystitis576.1 Cholangitis577.0 Acute pancreatitis577.1 Chronic pancreatitis577.8 Pancreatic multiple calculi590.00-590.9 Infections of the kidney
595.9 Recurrent cystitis596.4 Bladder atony596.53 Bladder paresis
599.0 Urinary tract infection, recurrent
607.84 Impotence of organic origin
65 GLUCOSE (NCD)
National Coverage Decision November 25, 2002
GLUCOSE TESTING (BLOOD)
608.89 Other disorders male genital organs616.10 Vulvovaginitis626.0 Amenorrhea626.4 Irregular menses628.9 Infertility - female648.00 Diabetes mellitus complicating pregnancy, childbirth or the puerperium,
unspecified as to episode of care or not applicable648.03 Diabetes mellitus complicating pregnancy, childbirth or the puerperium,
antipartum condition or complication648.04 Diabetes mellitus complicating pregnancy, childbirth or the puerperium,
postpartum condition or complication648.80 Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, unspecified as to episode of care or not applicable648.83 Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, antepartum condition or complication648.84 Abnormal glucose tolerance complicating pregnancy, childbirth or the
puerperium, postpartum condition or complication649.20-649.24 Bariatric surgery status complicating pregnancy, childbirth, or the
puerperium, unspecified as to episode of care or not applicable656.60-656.63 Fetal problems affecting management of mother - large for-date of fetus
657.00-657.03 Polyhydramnios680.0-680.9 Carbunde and furuncle686.00-686.9 Infections of skin and subcutaneous tissue698.0 Pruritus ani698.1 Pruritus of genital organs704.1 Hirsutism705.0 Anhidrosis707.00-707.9 Chronic ulcer of skin709.3 Degenerative skin disorders729.1 Myalgia730.07 Acute osteomyelitis of the ankle and foot730.17 Chronic osteomyelitis of ankle and foot730.27 Unspecified osteomyelitis of ankle and foot780.01 Coma780.02 Transient alteration of awareness780.09 Alteration of consciousness, other780.2 Syncope and collapse780.31 Febrile convulsions780.32 Complex febrile convulsions780.39 Seizures, not otherwise specified780.4 Dizziness and giddiness780.71-780.79 Malaise and fatigue780.8 Hyperhidrosis781.0 Abnormal involuntary movements782.0 Loss of vibratory sensation783.1 Abnormal weight gain783.21 Abnormal loss of weight783.5 Polydipsia783.6 Polyphagia785.0 Tachycardia785.4 Gangrene786.01 Hyperventilation
66 GLUCOSE (NCD)
National Coverage Decision November 25, 2002
GLUCOSE TESTING (BLOOD)
786.09 Dyspnea786.50 Chest pain, unspecified787.6 Full incontinence of feces787.61 Incomplete defecation787.62 Fecal smearing787.63 Fecal urgency787.91 Diarrhea788.41-788.43 Frequency of urination and polyuria789.1 Hepatomegaly790.21-790.29 Abnormal glucose tolerance test790.6 Other abnormal blood chemistry (hyperglycemia)791.0 Proteinuria791.5 Glycosuria796.1 Abnormal reflex799.4 Cachexia* V23.0-V23.9 Supervison of high risk pregnancyV58.63-V58.65 Long-term (current) use of antiplatelet/antithrombotic
V58.67 Long-term use of insulin
V58.69 Long term current use of other medicationV67.2 Follow-up examination, following chemotherapyV67.51 Follow up examination with high-risk medication not elsewhere classified
V77.1 ** Screening for diabetes mellitus. **This screening allowed once a year with
this code. If additional Glucose tests are performed, they must be diagnostic
or must have an ABN for frequency. Covered for CPT code 82947 only.
* V22.0-V23.9 OB Patients Only
Reviewed: April 2013
67 GLUCOSE (NCD)
National Coverage Decision November 25, 2002
CPT: 84702 HCG Quantitative; (Human Chorionic Gonadotropin)
158.0 Malignant neoplasm of retroperitoneum
158.8 Malignant neoplasm of specified parts of peritoneum
164.2 Malignant neoplasm of anterior mediastinum
164.3 Malignant neoplasm of posterior mediastinum
164.8 Malignant neoplasm, other (includes malignant neoplasm of contiguous
overlapping sites of thymus, heart, and mediastinum whose point of origin
cannot be determined164.9 Malignant neoplasm of mediastinum, part specified
181 Malignant neoplasm of placenta
183.0 Malignant neoplasm of ovary
183.8 Other specified sites of uterine adnexa
186.0 Malignant neoplasm of undescended testis
186.9 Malignant neoplasm of other and unspecified testis
194.4 Malignant neoplasm of pineal gland
197.1 Secondary malignant neoplasm of mediastinum
197.6 Secondary malignant neoplasm of ovary
198.6 Secondary malignant neoplasm of ovary
198.82 Secondary malignant neoplasm of other genital organs
236.1 Neoplasm of uncertain behavior, placenta
338.3 Neoplasm related pain (acute)(chronic)
623.8 Vaginal bleeding
625.9 Pelvic pain
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
633.90-633.91 Unspecified ectopic pregnancy
634.00-634.02 Spontaneous abortion, unspecified, complicated by genital tract and pelvic
infection640.00-640.03 Threatened abortion, unspecified as to episode of care
642.30-642.34 Transient hypertension of pregnancy, unspecified as to episode of care
642.40-642.74 Mild or unspecified pre-eclampsia, unspecified as to episode of care
642.90-642.94 Unspecified hypertension complicating pregnancy, childbirth, or the
puerperium, unspecified as to episode of care795.89 Other abnormal tumor markers
V10.09 Personal history of malignant neoplasm, other gastrointestinal sites
V10.29 Personal history of malignant neoplasm of other respiratory and intrathoracic
organsV10.43 Personal history of malignant neoplasm, ovary
V10.47 Personal history of malignant neoplasm, testis
V22.0-V22.1 Normal pregnancy
Reviewed: April 2013
HCG QUANTITATIVE
68 HCG QUANT (NCD)
National Coverage Decision November 25, 2002
CPT: 80074 Hepatitis Panel, Acute
070.0-070.9 Viral hepatitis
456.0-456.21 Esophageal varices with or without mention of bleeding
570 Acute and subacute necrosis of liver
571.5 Cirrhosis of liver without mention of alcohol
572.0-572.8 Liver abscess and sequelae of chronic liver disease
573.3 Hepatitis, unspecified
573.5 Hepatopulmonary syndrome
780.31-780.32 Febrile convulsions
780.33 Post traumatic seizures
780.71 Chronic fatigue syndrome
780.72 Functional quadriplegia
780.79 Other malaise and fatigue782.4 Jaundice, unspecified, not of newborn783.0-783.6 Symptoms concerning nutrition, metabolism, and development784.69 Other symbolic dysfunction787.01-787.03 Nausea and vomiting787.04 Bilious emesis789.00-789.09 Abdominal pain789.1 Hepatomegaly789.61 Localized abdominal tenderness (RUQ)789.7 Colic
790.4 Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase794.8 Non-specific abnormal results of function 996.82 Complication of transplanted organ, liverV72.85 Liver transplant recipient evaluation
Reviewed: April 2013
HEPATITIS PANEL, ACUTE
69 HEPATITIS PANEL, ACUTE (NCD)
National Coverage Decision November 25, 2002
CPT: 86689 Qualitative or semiquantitative immunoassays performed by multiple step
methods; HTLV or HIV antibody, confirmatory test (for example, Western Blot)CPT: 86701 Qualitative or semiquantitative immunoassays performed by multiple step
methods; HIV-1CPT: 86702 Qualitative or semiquantitative immunoassays performed by multiple step
methods; HIV-2CPT: 86703 Qualitative or semiquantitative immunoassays performed by multiple step
methods; HIV-1 and HIV-2, single assayCPT: 87390 Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple step method; HIV-1CPT: 87391 Infectious agent antigen detection by enzyme immunoassay technique,
qualitative or semiquantitative, multiple step method; HIV-2CPT: 87534 Infectious agent antigen by nucleic acid (DNA or RNA); HIV-1, direct probe
techniqueCPT: 87535 Infectious agent antigen by nucleic acid (DNA or RNA); HIV-1, amplified probe
techniqueCPT: 87537 Infectious agent antigen by nucleic acid (DNA or RNA); HIV-2, direct probe
techniqueCPT: 87538 Infectious agent antigen by nucleic acid (DNA or RNA); HIV-2, amplified probe
technique
003.1 Salmonella septicemia
007.2 Coccidiosis (Isoporiasis)
007.4 Cryptosporidiosis007.8 Other specified protozoal intestinal diseases010.00-010.96 Primary tuberculous infection011.00-011.96 Pulmonary tuberculosis012.00-012.86 Other respiratory tuberculosis013.00-013.96 Tuberculosis of meninges and central nervous system014.00-014.86 Tuberculosis of intestines, peritoneum and mesenteric glands015.00-015.96 Tuberculosis of bones and joints016.00-016.96 Tuberculosis of genitourinary system017.00-017.96 Tuberculosis of other organs018.00-018.96 Miliary tuberculosis027.0 Listeriosis031.0-031.9 Diseases due to other mycobacteria038.2 Pneumococcal septicemia038.43 Septicemia (Pseudomonas)039.0-039.9 Actinomycotic infections (includes Nocardia)041.7 Pseudomonas infection042 HIV disease (Acute retroviral syndrome, AIDS-related complex)046.3 Progressive multifocal leukoencephalopathy049.0-049.9 Other non-arthropod-borne viral diseases of central nervous system052.0-052.8 Chickenpox (with complication)053.0-053.9 Herpes zoster054.0-054.9 Herpes simplex055.0-055.8 Measles (with complication)070.20-070.23 Viral hepatitis B with hepatic coma070.30-070.33 Viral hepatitis B without mention of hepatic coma070.41 Acute or unspecified hepatitis C with hepatic coma070.42 Hepatitis delta without mention of active hepatitis B disease with hepatic
070.44 Chronic hepatitis C with hepatic coma
HUMAN IMMUNODEFICIENCY VIRUS TESTING (Diagnosis)
70 HIV DIAGNOSIS (NCD)
National Coverage Decision November 25, 2002
HUMAN IMMUNODEFICIENCY VIRUS TESTING (Diagnosis)
070.49 Other specified viral hepatitis with hepatic coma070.51 Acute or unspecified hepatitis C without hepatic coma070.52 Hepatitis delta without mention of active hepatitis B disease without hepatic
coma070.54 Chronic hepatitis C without hepatic coma070.59 Other specified viral hepatitis without hepatic coma070.6 Unspecified viral hepatitis with hepatic coma070.70 Viral hepatitis070.71 Viral hepatitis070.9 Unspecified viral hepatitis without hepatic coma078.0 Molluscum contagiosum078.10-078.19 Viral warts078.3 Cat-scratch disease078.5 Cytomegaloviral disease078.88 Other specified diseases due to Chlamydiae079.50 Retrovirus unspecified079.51 HTLV-I079.52 HTLV-II079.53 Human immunodeficiency virus, type 2079.59 Other specified Retrovirus079.88 Other specified chlamydial infection079.98 Unspecified chlamydial infection085.0-085.9 Leishmaniasis088.0 Bartonellosis090.0-090.9 Congenital syphilis091.0-091.9 Early syphilis symptomatic092.0-092.9 Early syphilis, latent093.0-093.9 Cardiovascular syphilis094.0-094.9 Neurosyphilis095.0-095.9 Other forms of late syphilis, with symptoms096 Late syphilis, latent097.0-097.9 Other and unspecified syphilis098.0-098.89 Gonococcal infections099.0 Chancroid099.1 Lymphogranuloma venereum099.2 Granuloma inguinale099.3 Reiter's disease099.40-099.49 Other nongonococcal urethritis099.50-099.59 Other venereal diseases due to Chlamydia trachomatis099.8 Other specified venereal disease099.9 Venereal Disease unspecified110.1 Dermatophytosis of nail111.0 Ityriasis versicolor112.0-112.9 Candidiasis114.0-114.9 Coccidioidmycosis115.00-115.99 Histoplasmosis116.0-116.2 Blastomycotic infection117.3 Aspergillosis117.5 Cryptococcosis118 Opportunistic mycoses127.2 Strongyloidiasis130.0-130.9 Toxoplasmosis
71 HIV DIAGNOSIS (NCD)
National Coverage Decision November 25, 2002
HUMAN IMMUNODEFICIENCY VIRUS TESTING (Diagnosis)
131.01 Trichomonal vulvovaginitis132.2 Phthirus pubis133.0 Scabies136.21-136.29 Specific infections by free living amebae136.3 Pneumocystosis136.8 Other specified infectious and parasitic disease (for example,
microsporidiosis)176.0-176.9 Kaposi's sarcoma
180.0-180.9 Malignant neoplasm of cervix uteri200.20-200.28 Burkitt's tumor or lymphoma200.80-200.88 Lymphosarcoma, other named variants201.00-201.98 Hodgkin's disease263.0 Malnutrition of moderate degree263.1 Malnutrition of mild degree263.9 Unspecified protein-calorie malnutrition280.0-280.9 Iron deficiency anemias285.9 Anemia, unspecified287.30-278.39 Primary thrombocytopenia288.00-288.09 Agranulocytosis288.4 Hemophagocytic syndromes288.50-288.69 Leukocytopenia288.8 Other specified disease of white blood cells289.53 Neutropenic splenomegaly294.8 Other persistent mental disorders due to conditions classified elsewhere
310.1 Personality change due to conditions classified elsewhere
322.2 Chronic meningitis331.19 Other frontotemporal dementia331.83 Mild cognitive impairment, so stated336.9 Unspecified disease of spinal cord348.30 Encephalopathy unspecified348.39 Other encephalopathy354.0-354.9 Mononeuritis of upper limbs and mononeuritis multiplex356.8 Other specified idiopathic peripheral neuropathy363.20 Chorioretinitis, unspecified425.4 Other primary cardiomyopathies473.0-473.9 Chronic sinusitis481-482.9 Pneumococcal pneumonia484.1 Pneumonia in cytomegalic inclusion disease486 Pneumonia, organism unspecified512.81 Primary spontaneous pneumothorax512.82 Secondary spontaneous pneumothorax512.83 Chronic pneumothorax516.8 Other specified alveolar and parietoalveolar pneumonopathies528.2 Oral aphthae528.6 Leukoplakia of oral mucosa530.20 Ulcer of esophagus530.21 Ulcer of esophagus with bleeding530.85 Barrett's esophagus583.9 Nephropathy with unspecified pathological lesion in kidney588.81, 588.89 Other specified disorders resulting from impaired renal function647.60-647.64 Other viral diseases complicating pregnancy (use for HIV I and II)682.0-682.9 Other cellulitis and abscess
72 HIV DIAGNOSIS (NCD)
National Coverage Decision November 25, 2002
HUMAN IMMUNODEFICIENCY VIRUS TESTING (Diagnosis)
690.10-690.18 Seborrheic dermatitis696.1 Other psoriasis698.3 Lichenification and lichen simplex chronicus704.8 Other specified diseases of hair and hair follicles706.0-706.9 Diseases of sebaceous glands780.60-780.65 Fever and other physiologic disturbances of temperature regulation780.66 Febrile nonhemolytic transfusion reaction780.79 Other malaise and fatigue783.21 Abnormal loss of weight783.40 Lack of expected normal physiological development785.6 Enlargement of lymph nodes786.00 Respiratory abnormality, unspecified786.05 Shortness of breath786.2 Cough786.30 Hemoptysis, unspecified786.31 Acute idiopathic pulmonary hemorrhage in infants (AIPHI)786.39 Other hemoptysis
786.4 Abnormal sputum787.91 Diarrhea795.71 Nonspecific serologic evidence of human immunodeficiency virus
799.4 Wasting diseaseV01.71, V01.79 Contact with or exposure to communicable diseases, other viral diseases
V71.5 Rape
Reviewed: April 2013
73 HIV DIAGNOSIS (NCD)
National Coverage Decision November 25, 2002
CPT: 87536 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1 quantification
CPT: 87539 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2 quantification
042 Human immunodeficiency virus (HIV) disease
079.53 Human immunodeficiency virus, type 2 [HIV-2]
647.60-647.64 Other viral diseases complicating pregnancy (including HIV-I and II)
795.71 Non-specific serologic evidence of human immunodeficiency virus (HIV)
V08 Asymptomatic human immunodeficiency virus (HIV) infection status
Reviewed: April 2013
HUMAN IMMUNODEFICIENCY VIRUS TESTING (Prognosis Including Monitoring)
74 HIV (NCD)
National Coverage Decision November 25, 2002
CPT: 82728 Ferritin
CPT: 83540 Iron
CPT: 83550 Iron Binding capacity
CPT: 84466 Transferrin
002.0-002.9 Typhoid and paratyphoid fevers
003.0-003.9 Other salmonella infections
006.0-006.9 Amebiasis
007.0-007.9 Other protozoal intestinal diseases
008.00-008.8 Intestinal infections due to other organisms
009.0-009.3 Ill-defined intestinal infections
011.50-011.56 Tuberculous bronchiectasis
014.00-014.86 Tuberculosis of intestines, peritoneum, and mesenteric glands
015.00-015.96 Tuberculosis of bones and joints016.00-016.06 Tuberculosis of kidney016.10-016.16 Tuberculosis of bladder016.20-016.26 Tuberculosis of ureter016.30-016.36 Tuberculosis of other urinary organs042 Human Immunodeficiency virus (HIV) disease070.0-070.9 Viral hepatitis140.0-149.9 Malignant neoplasm of lip oral cavity and pharynx150.0-159.9 Malignant neoplasm of digestive organs and peritoneum160.0-165.9 Malignant neoplasm of respiratory and intrathoracic organs170.0-176.9 Malignant neoplasm of bone, connective tissue, skin and breast179-189.9 Malignant neoplasm of genitourinary organs190.0-199.2 Malignant neoplasm without specification of site200.00-208.92 Malignant neoplasm of lymphatic and hematopoietic tissue209.00-209.03 Benign carcinoid tumors of the small intestine209.10-209.17 Benign carcinoid tumors of the appendix, large intestine and rectum209.20-209.29 Benign carcinoid tumors of other and unspecified sites209.30 Malignant poorly differentiated neuroendocrine carcinoma, any site209.31-209.36 Merkel cell carcinoma209.40-209.43 Malignant carcinoid tumors of the small intestine209.50-209.57 Malignant carcinoid tumors of the appendix, large intestine and rectum
209.60-209.69 Malignant carcinoid tumors of other and unspecified sites209.70 Secondary neuroendocrine tumor, unspecified site209.71 Secondary neuroendocrine tumor of distant lymph nodes209.72 Secondary neuroendocrine tumor of liver209.73 Secondary neuroendocrine tumor of bone209.74 Secondary neuroendocrine tumor of peritoneum209.75 Secondary Merkel cell carcinoma209.79 Secondary neuroendocrine tumor of other sites210.0-229.9 Benign neoplasms230.0-234.9 Carcinoma in situ235.0-235.9 Neoplasms of uncertain behavior of digestive and respiratory systems236.0-236.99 Neoplasms of uncertain behavior of genitourinary organs237.0-237.72 Neoplasms of uncertain behavior of endocrine glands and nervous system
237.73 Schwannomatosis237.79 Other neurofibromatosis237.9 Other and uncertain parts of the nervous system
IRON STUDIES; SERUM
75 IRON STUDIES (NCD)
National Coverage Decision November 25, 2002
IRON STUDIES; SERUM
238.0-238.6 Neoplasms of uncertain behavior of other and unspecified sites and tissues
238.71-238.76 Neoplasms of other lymphatic and hematopoietic tissues238.77 Post-transplant lymphoproliferative disorder (PTLD)238.79, 238.8, 238.9 Neoplasms of uncertain behavior239.0-239.7 Neoplasms of unspecified nature239.81 Neoplasms of unspecified nature, retina and choroid239.89 Neoplasms of unspecified nature, other specified sites239.9 Neoplasms of unspecified nature, site unspecified249.00-249.91 Secondary Diabetes Mellitus, with or without various manifestations250.00-250.93 Diabetes mellitus253.2 Panhypopituitarism253.7 Iatrogenic pituitary disorders253.8 Other disorders of the pituitary and other syndromes of
diencephalohypophysial origin256.31-256.39 Other ovarian failure257.2 Other testicular hypofunction260 Kwashiorkor261 Nutritional marasmus262 Other severe protein-calorie malnutrition263.0-263.9 Other and unspecified protein-calorie malnutrition275.01 Hereditary hemochromatosis275.02 Hemochromatosis due to repeated red blood cell transfusions275.03 Other hemochromatosis275.09 Other disorders of iron metabolism277.1 Disorders of porphyrin metabolism280.0-280.9 Iron deficiency anemias281.0-281.9 Other deficiency anemias282.40-282.49 Thalassemias282.60-282.63 Sickle cell anemia282.64 Sickle-cell/Hb-C disease with crisis282.68 Other sickle-cell disease without crisis282.69 Sickle cell anemia, other285.0 Sideroblastic anemia (includes hemochromatosis with refractory anemia)
285.1 Acute post-hemorrhagic anemia
285.21 Anemia in end-stage renal disease285.3 Antineoplastic chemotherapy induced anemia285.9 Anemia, unspecified286.0-286.9 Coagulation defects ( congenital factor disorders)287.0-287.39 Allergic purpura; qualitative platelet defects; other non-thrombocytopenic
purpuras; primary thrombocytopenia287.41 Posttransfusion purpura287.49 Other secondary thrombocytopenia287.5-287.9 Thrombocytopenia, unspecified; other specified and unspecified hemorrhagic
conditions289.52 Splenic sequestration306.4 Physiological malfunction arising from mental factors, gastrointestinal307.1 Anorexia nervosa307.50-307.59 Other and unspecified disorders of eating403.01 Hypertensive chronic kidney disease, malignant, with chronic kidney disease
stage V or end stage renal disease403.11 Hypertensive chronic kidney disease, benign with chronic kidney disease
stage V or end stage renal disease
76 IRON STUDIES (NCD)
National Coverage Decision November 25, 2002
IRON STUDIES; SERUM
403.91 Hypertensive chronic kidney disease, unspecified, with chronic kidney
disease stage V or end stage renal disease404.02 Hypertensive chronic kidney disease, malignant, without heart failure and
with chronic kidney disease stage V or end stage renal disease404.03 Hypertensive heart and chronic kidney disease, with heart failure and with
chronic kidney disease stage V or end stage renal disease404.12 Hypertensive heart and chronic kidney disease, benign, without heart failure
and with chronic kidney disease stage V or end stage renal disease
404.13 Hypertensive heart and chronic kidney disease, benign, with heart failure and
chronic kidney disease stage V or end stage renal disease404.92 Hypertensive heart and chronic kidney disease, unspecified, without heart
failure and with chronic kidney disease stage V or end stage renal disease
404.93 Hypertensive heart and chronic kidney disease, unspecified, with heart failure
and chronic kidney disease stage V or end stage renal disease
425.4 Other primary cardiomyopathies425.5 Alcoholic cardiomyopathy425.7 Nutritional and metabolic cardiomyopathy425.8 Cardiomyopathy in other diseases classified elsewhere425.9 Secondary cardiomyopathy, unspecified426.0-426.9 Conduction disorders427.0-427.9 Cardiac dysrhythmias428.0-428.9 Heart Failure530.7 Gastroesophageal laceration-hemorrhage syndrome
530.82 Esophageal hemorrhage531.00-531.91 Gastric ulcer532.00-532.91 Duodenal ulcer533.00-533.91 Peptic ulcer, site unspecified
534.00-534.91 Gastrojejunal ulcer535.00-535.71 Gastritis and duodenitis536.0-536.9 Disorders of function of stomach537.83 Angiodysplasia of stomach and duodenum with hemorrhage537.84 Dielulafoy Lesion (Hemorrhagic) of stomach and duodenum
555.0-555.9 Regional enteritis556.0-556.9 Ulcerative colitis557.0 Acute vascular insufficiency of intestine557.1 Chronic vascular insufficiency of intestine562.02 Diverticulosis of small intestine with hemorrhage562.03 Diverticulitis of small intestine with hemorrhage562.12 Diverticulosis of colon with hemorrhage562.13 Diverticulitis of colon with hemorrhage569.3 Hemorrhage of rectum an anus569.85 Angiodysplasia of intestine with hemorrhage569.86 Dieulafoy lesion (Hemorrhagic) of intestine569.87 Vomiting of fecal matter570 Acute and subacute necrosis of liver571.0-571.9 Chronic liver disease and cirrhosis572.0-572.8 Liver abscess and sequelae of chronic liver disease573.0-573.9 Other disorders of liver
578.0-578.9 Gastrointestinal hemorrhage579.0-579.3 Intestinal malabsorption
579.8-579.9 Other specified and unspecified intestinal malabsorption
77 IRON STUDIES (NCD)
National Coverage Decision November 25, 2002
IRON STUDIES; SERUM
581.0-581.9 Nephrotic syndrome585.4-585.9 Chronic renal failure586 Renal failure, unspecified608.3 Atrophy of testis626.0-626.9 Disorders of menstruation and other abnormal bleeding from female genital
tract627.0 Premenopausal menorrhagia627.1 Postmenopausal bleeding648.20-648.24 Other current conditions in the mother classifiable elsewhere, but
complicating pregnancy, childbirth , or puerperium: Anemia698.0-698.9 Pruritus and related conditions704.00-704.09 Alopecia709.00-709.09 Dyschromia713.0 Arthropathy associated with other endocrine and metabolic disorders716.40-716.99 Other and unspecified arthropathies719.40-719.49 Pain in joint773.2 Hemolytic disease due to other and unspecified isoimmunization773.3 Hydrops fetalis due to isoimmunization773.4 Kernicterus due to isoimmunization773.5 Late anemia due to isoimmunization783.9 Other symptoms concerning nutrition, metabolism and development790.01-790.09 Abnormality of red blood cells790.4 Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase
790.5 Other nonspecific abnormal serum enzyme levels790.6 Other abnormal blood chemistry799.4 Cachexia964.0 Poisoning by agents primarily affecting blood constituents, iron compounds
984.0-984.9 Toxic effect of lead and its compounds (including fumes)996.85 Complications of transplanted organ, bone marrow999.80 Transfusion reaction, unspecified999.83 Hemolytic transfusion reaction, incompatibility unspecified999.84 Acute hemolytic transfusion reaction, incompatibility unspecified999.85 Delayed hemolytic transfusion reaction, incompatibility unspecified999.89 Other transfusion reactionV08 Asymptomatic HIV infectionV12.1 Personal history of nutritional deficiencyV12.3 Personal history of diseases of blood and blood forming organsV15.1 Personal history of surgery to heart and great vesselsV15.21 Personal history of undergoing in utero procedure during pregnancyV15.22 Personal history of undergoing in utero procedure while a fetusV15.29 Personal history of surgery of other major organsV43.21-V43.22 Heart replaced by other meansV43.3 Heart valve replaces by other meansV43.4 Blood vessel replaced by other meansV43.60 Unspecified joint replaced by other meansV56.0 Extracorporeal dialysisV56.8 Other dialysis
Reviewed: April 2013
78 IRON STUDIES (NCD)
National Coverage Decision November 25, 2002
CPT: 80061 Lipid PanelCPT: 82465 Cholesterol, serum or whole blood, totalCPT: 83700 Lipoprotein, blood; electophorectic CPT: 83701 Lipoprotein, blood: high fractionation CPT: 83704 Lipoprotein blood: quantitation of lipoprotein particle numbers and
lipoprotein particles subclassesCPT: 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)
CPT: 83721 Lipoprotein, direct measurement, LDL cholesterolCPT: 84478 Triglycerides
242.00-245.9 Disorders of the thyroid gland with hormonal dysfunction249.00-249.91 Secondary diabetes mellitus with renal manifestations250.00-250.93 Diabetes mellitus255.0 Cushing's syndrome260 Kwashiorkor261 Nutritional marasmus262 Other severe, protein-calorie malnutrition263.0 Malnutrition of moderate degree263.1 Malnutrition of mild degree263.8 Other protein-calorie malnutrition263.9 Unspecified protein-calorie malnutrition270.0 Disturbances of amino-acid transport271.1 Galactosemia272.0 Pure hypercholesterolemia272.1 Hyperglyceridemia272.2 Mixed hyperlipidemia (tuberous xanthoma)272.3 Hyperchylomicronemia272.4 Other and unspecified hyperlipidemia (unspecified xanthoma)272.5 Lipoprotein deficiencies272.6 Lipodystrophy272.7 Lipidoses272.8 Other disorders of lipoid metabolism272.9 Unspecified disorders of lipoid metabolism277.30-277.39 Amyloidosis278.00 Obesity278.01 Morbid obesity278.02 Overweight278.03 Obesity hypoventilation syndrome303.90-303.92 Alcoholism362.10-362.16 Other background retinopathy and retinal vascular change362.30-362.34 Retinal vascular occlusion362.82 Retinal exudates and deposits371.41 Senile corneal changes374.51 Xanthelasma379.22 Crystalline deposits in vitreous388.00 Degenerative and vascular disorder of ear, unspecified388.02 Transient ischemic deafness401.0, 401.1,401.9 Essential hypertension402.00-402.91 Hypertensive heart disease403.00-403.91 Hypertensive renal disease
LIPID PROFILE AND CHOLESTEROL TESTING
Frequency Limitation: See "Frequency Test List" for specifics.
79 LIPID (NCD)
National Coverage Decision November 25, 2002
LIPID PROFILE AND CHOLESTEROL TESTING
404.00-404.93 Hypertensive heart and renal disease405.01-405.99 Secondary hypertension410.00-410.92 Acute myocardial infarction411.0-411.1 Other acute and subacute forms of ischemic heart disease411.81 Coronary occlusion without myocardial infarction411.89 Other acute and subacute ischemic heart disease412 Old myocardial infarction413.0-413.1 Angina pectoris413.9 Other and unspecified angina pectoris414.00-414.03 Coronary atherosclerosis414.04 Coronary atherosclerosis of artery bypass graft414.05 Coronary athrscl-unspec graft414.06 Coronary atherosclerosis of coronary artery of transplanted heart414.07 Coronary atherosclerosis, of bypass graft (artery)(vein) of transplanted heart
414.10 Aneurysm, heart (wall)414.11 Coronary vessel aneurysm414.12 Dissection of coronary artery414.19 Other aneurysm of heart
414.3 Coronary atherosclerosis due to lipid rich plaque
414.4 Coronary atherosclerosis due to calcified coronary lesion414.8 Other specified forms of chronic ischemic heart disease414.9 Chronic ischemic heart disease, unspecified428.0-428.9 Heart failure429.2 Heart disease, unspecified429.9 Heart disease NOS431 Intracerebral hemorrhage433.00-433.91 Occlusion and stenosis of precerebral arteries434.00-434.91 Occlusion of cerebral arteries435.0-435.9 Transient cerebral ischemia437.0 Cerebral atherosclerosis437.1 Other generalized ischemic cerebrovascular disease437.5 Moyamoya disease438.0 Late effects of cerebrovascular disease438.13 Late effects of cerebrovascular disease, dysarthria438.14 Late effects of cerebrovascular disease, fluency disorder438.9 Unspecified late effects of cerebrovascular disease440.0-440.9 Arteriosclerosis441.00-441.9 Aortic aneurysms442.0 Upper extremity aneurysm442.1 Renal artery aneurysm442.2 Iliac artery aneurysm444.01, 444.09,
444.1-444.9
Arterial embolism and thrombosis
557.1 Chronic vascular insufficiency of intestine571.8 Other chronic non-alcoholic liver disease571.9 Unspecified chronic liver disease without mention of alcohol573.5 Hepatopulmonary syndrome573.8 Other specified disorders of liver573.9 Unspecified disorders of liver577.0-577.9 Pancreatic disease579.3 Other and unspecified postsurgical nonabsorption579.8 Other specified intestinal malabsorption
80 LIPID (NCD)
National Coverage Decision November 25, 2002
LIPID PROFILE AND CHOLESTEROL TESTING
581.0-581.9 Nephrotic syndrome584.5 Acute renal failure with lesion of tubular necrosis585.4-585.9 Chronic renal failure588.0 Renal osteodystrophy588.1 Nephrogenic diabetes insipidus588.81, 588.89 Other specified disorders resulting from impaired renal function588.9 Unspecified disorder resulting from impaired renal function607.84 Impotence of organic origin, penis disorder646.70-646.71 Liver disorders in pregnancy 646.73 Liver and biliary tract disorders in pregnancy, antepartum condition or
complication648.10-648.14 Thyroid dysfunction in pregnancy and the puerperium696.0 Psoriatic Arthropathy696.1 Other psoriasis751.61 Biliary atresia764.10-764.19 "Light-For-Dates" with signs of fetal malnutrition786.50 Chest pain unspecified786.51 Precordial pain786.59 Chest pain, other789.1 Hepatomegaly790.4 Abnormal transaminase790.5 Abnormal alkaline phosphatase790.6 Other abnormal blood chemistry793.4 Abnormal imaging study987.9 Toxic effect of unspecified gas or vapor996.81 Complication of transplanted organ, kidneyV42.0 Transplanted organ, kidneyV42.7 Organ Replacement by transplant, liverV58.63-V58.64 Long-term (current) use of antiplatelet/antithromboticV58.69 Long-term (current) use of other medicationsV81.0, V81.1, V81.2 ** Screening for other unspecified Cardiovascular conditions. ** This screening
is only allowed 1 every 5 years with these codes. If additional Lipids tests are
performed, they must be diagnostic or must have an ABN for frequency.
Covered for CPT codes 80061, 82465, 83718 and 84478 only.
Reviewed: April 2013
81 LIPID (NCD)
Medicare A Medical Policy April 16, 2006
CPT: 83735 Magnesium
249.00-249.91 Secondary Diabetes Mellitus, with or without various manifestations250.00-250.03 Diabetes mellitus without mention of complication, type II or unspecified type,
not stated as uncontrolled250.10-250.13 Diabetes with ketoacidosis250.20-250.23 Diabetes with hyperosmolarity250.30-250.33 Diabetes with other coma250.40-250.43 Diabetes with renal manifestations250.50-250.53 Diabetes with ophthalmic manifestations250.60-250.63 Diabetes with neurological manifestations250.70-250.73 Diabetes with peripheral circulatory disorders250.80-250.83 Diabetes with other specified manifestations250.90-250.93 Diabetes with unspecified complication252.00-252.08 Hyperparathyroidism252.1 Hypoparathyroidism252.8 Other specified disorders of the parathyroid gland252.9 Unspecified disorders of parathyroid gland255.10-255.14 Hyperaldosteronism259.3 Ectopic hormone secretion, not elsewhere classified260 Kwashiorkor261 Nutritional marasmus262 Other severe, protein-calorie malnutrition263.0 Malnutrition of moderate degree263.8 Other protein-calorie malnutrition263.9 Unspecified protein-calorie malnutrition275.2-275.3 Disorders of magnesium metabolism275.5 Hungry bone syndrome275.40-275.49 Disorders of calcium metabolism276.0 Hyperosmolality and/or hypernatremia276.1 Hyposmolality and/or hyponatremia276.2 Acidosis276.4 Mixed acid-base balance disorder276.50-276.52 Volume depletion276.7 Hyperpotassemia276.8 Hypopotassemia276.9 Electrolyte and fluid disorders not elsewhere classified278.8 Other hyperalimentation286.9 Other and unspecified coagulation defects289.51 Chronic congestive splenomegaly289.52 Splenic sequestration289.53 Neutropenic splenomegaly289.59 Other diseases of spleen293.0-293.1 Transient acute and subacute delirium298.9 Unspecified psychosis303.00 - 303.03 Acute alcoholic intoxication in alcoholism303.90-303.93 Other and unspecified alcohol dependence, chronic alcoholism307.1 Anorexia nervosa307.20 Tic disorder, unspecified307.22 Chronic motor tic disorder307.50-307.54 Eating disorder, unspecified307.59 Other disorders of eating
MAGNESIUM
82 MAGNESIUM (LCD)
Medicare A Medical Policy April 16, 2006
MAGNESIUM
333.2 Myoclonus333.3 Tics of organic origin336.1 Vascular myelopathies345.60-345.61 Infantile spasms357.4 Polyneuropathy in other diseases classified elsewhere359.5 Myopathy in endocrine diseases classified elsewhere359.81 Critical illness myopathy359.89 Other myopathies359.9 Myopathy, unspecified
401.0 Malignant essential hypertension
401.1 Benign essential hypertension401.9 Unspecified essential hypertension402 Malignant hypertensive heart disease without heart failure402.01 Malignant hypertensive heart disease with heart failure402.1 Benign hypertensive heart disease without heart failure402.11 Benign hypertensive heart disease with heart failure402.9 Unspecified hypertensive heart disease without heart failure402.91 Unspecified hypertensive heart disease with heart failure403.00 Hypertensive kidney disease, malignant, without chronic kidney disease
403.01 Malignant hypertensive renal disease with renal failure403.10-403.11 Benign hypertensive renal disease with renal failure403.90-403.91 Unspecified hypertensive renal disease with renal failure404.00 Hypertensive heart and kidney disease, malignant, without hearth failure or
chronic kidney disease404.01 Hypertensive heart and kidney disease, malignant, with heart failure404.02 Malignant hypertensive heart and renal disease with renal failure404.03 Malignant hypertensive heart and renal disease with heart failure and renal
failure404.10-404.11 Hypertensive heart and kidney disease, benign with heart failure404.12 Benign hypertensive heart and renal disease with renal failure404.13 Benign hypertensive heart and renal disease with heart failure and renal
failure404.90-404.91 Hypertensive heart and kidney disease, unspecified, with heart failure404.92 Unspecified hypertensive heart and renal disease with renal failure404.93 Unspecified hypertensive heart and renal disease with heart failure and renal
failure405.01 Malignant renovascular hypertension405.09 Other malignant secondary hypertension405.11 Benign renovascular hypertension405.19 Other benign secondary hypertension405.91 Unspecified renovascular hypertension405.99 Other unspecified secondary hypertension410.00-410.02 Acute myocardial infarction of anterolateral wall410.10-410.12 Acute myocardial infarction of other anterior wall410.20-410.22 Acute myocardial infarction of inferolateral wall410.30-410.32 Acute myocardial infarction of inferoposterior wall410.40-410.42 Acute myocardial infarction of other inferior wall410.50-410.52 Acute myocardial infarction of other lateral wall410.60-410.62 Acute myocardial infarction, true posterior wall410.70-410.72 Acute myocardial infarction, subendocardial410.80-410.82 Acute myocardial infarction of other specified site410.90-410.92 Acute myocardial infarction of unspecified site
83 MAGNESIUM (LCD)
Medicare A Medical Policy April 16, 2006
MAGNESIUM
411.81 Coronary occlusion without myocardial infarction414.8 Other specified forms of chronic ischemic heart disease415.11 Latrogenic pulmonary embolism and infarction415.19 Other pulmonary embolism and infarction425.4 Other primary cardiomyopathies427.0-427.2 Paroxysmal supraventricular, ventricular, and unspecified tachycardia
427.31-427.32 Atrial fibrillation and flutter427.41-427.42 Ventricular fibrillation and flutter427.5 Cardiac arrest427.60-427.61 Premature beats427.69 Premature beats, other427.81 Sinoatrial node dysfunction427.89 Sinoatrial node dysfunction, other427.9 Cardiac dysrhythmia428.0 Congestive Heart Failure, Unspecified429.79 Certain sequelae of myocardial infarction not elsewhere classified, other
429.83 Takotsubo syndrome429.89 Other ill-defined heart disease458.0-458.29 Hypotension458.9 Hypotension, unspecified536.2 Persistent vomiting558.41 Eosinophilic gastroenteritis558.9 Other and unspecified noninfectious gastroenteritis and colitis560.81 Intestinal or peritoneal adhesions with obstruction (postoperative)
569.60 Colostomy and enterostomy complication unspecified569.81 fistula of intestine excluding rectum and anus579.0 Celiac disease579.2 Blind loop syndrome579.3 Other and unspecified postsurgical nonabsorption579.8 Other specified intestinal malabsorption579.9 Unspecified intestinal malabsorption580.0 - 580.9 Acute glomerulonephritis581.0 - 581.9 Nephrotic syndrome582.0 - 582.9 Chronic glomerulonephritis583.0 - 583.9 Nephritis and nephropathy, not specified as acute of chronic584.5-584.9 Acute kidney failure585.1 - 585.9 Chronic renal failure586 Renal failure, unspecified587 Renal sclerosis, unspecified588.0 Renal osteodystrophy588.1 Nephrogeni diabetes insipidus588.81, 588.89 Other specified disorder resulting from impaired renal function593.81 Vascular disorders of kidney593.9 Disorder of the kidney and ureter, unspecified632 Missed abortion634.10-634.12 Spontaneous abortion; complicated by delay or excessive hemorrhage
634.20-634.22 Spontaneous abortion; unspecified complicated by damage to pelvic organs
or tissues634.30-634.32 Spontaneous abortion; complicated by renal failure634.40-634.42 Spontaneous abortion; complicated by metabolic disorder634.60-635.62 Spontaneous abortion; complicated by embolism
84 MAGNESIUM (LCD)
Medicare A Medical Policy April 16, 2006
MAGNESIUM
634.70-634.72 Spontaneous abortion; with other specified complications634.80-634.82 Spontaneous abortion; with unspecified complications635.10-635.12 Legally induced abortion; complicated by delay or excessive hemorrhage
635.30-635.32 Legally induced abortion; complicated by renal failure635.40-635.42 Legally induced abortion; complicated by metabolic disorder635.50-635.52 Legally induced abortion; complicated by shock635.60-635.62 Legally induced abortion; complicated by embolism635.70-635.72 Legally induced abortion; with other specified complications635.80-635.82 Legally induced abortion; with unspecified complications636.10-636.12 Illegally induced abortion; complicated by delay or excessive hemorrhage
636.30-636.32 Illegally induced abortion; complicated by renal failure636.40-636.42 Illegally induced abortion; complicated by metabolic disorder636.50-636.52 Illegally induced abortion; complicated by shock636.60-636.62 Illegally induced abortion; complicated by embolism636.70-636.72 Illegally induced abortion; with other specified complications636.80-636.82 Illegally induced abortion; with unspecified complications637.10-637.12 Unspecified abortion; complicated by delay or excessive hemorrhage637.20-637.22 Unspecified abortion; complicated by damage to pelvic organs or tissues637.30-637.32 Unspecified abortion; complicated by renal failure637.40-637.42 Unspecified abortion; complicated by metabolic disorder637.50-637.52 Unspecified abortion; complicated by shock637.60-637.62 Unspecified abortion; complicated by embolism637.70-637.72 Unspecified abortion; with other specified complications637.80-637.82 Unspecified abortion; with unspecified complications638.1-638.9 Failed attempted abortion; complicated by delay or excessive hemorrhage
639.1 - 639.9 Complications following abortion and ectopic and molar pregnancies640.00,640.01,640.03 Threatened abortion640.80,640.81,640.83 Other specified hemorrhage in early pregnancy640.90,640.91,640.93 Unspecified hemorrhage in early pregnancy641.00,641.01,641.03 Placenta previa without hemorrhage641.10,641.11,641.13 Hemorrhage from placenta previa641.20,641.21,641.23 Premature separation of placenta641.30,641.31,641.33 Antepartum hemorrhage associated with coagulation defects641.80,641.81,641.83 Other antepartum hemorrhage641.90-641.93 Unspecified antepartum hemorrhage642.00-642.04 Hypertension complicating pregnancy, childbirth and the pueperium642.10-642.14 Hypertension secondary to renal disease, complicating pregnancy, childbirth,
and the puerperium642.20-642.24 Other pre-existing hypertension complicating pregnancy, childbirth and the
puerperium642.30-642.34 Transient hypertension of pregnancy642.40-642.44 Mild or unspecified pre-eclampsia642.50-642.54 Severe pre-eclampsia642.60-642.64 Eclampsia642.70-642.74 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension
642.90-642.94 Unspecified hypertension complicating pregnancy, childbirth or the
puerperium643.00,643.01,643.03 Mild hyperemesis gravidarum643.10,643.11,643.13 Hyperemesis gravidarum with metabolic disturbance643.20,643.21,643.23 Late vomiting of pregnancy643.80,643.81,643.83 Other vomiting complicating pregnancy643.90,643.91,643.93 Unspecified vomiting of pregnancy
85 MAGNESIUM (LCD)
Medicare A Medical Policy April 16, 2006
MAGNESIUM
646.20-646.24 Unspecified renal disease in pregnancy without mention of hypertension
646.80-646.84 Other specified complications of pregnancy646.90-646.91 Unspecified complication of pregnancy646.93 Antepartum condition or complication648.00-648.04 Diabetes mellitus, pregnancy648.90-648.94 Other current conditions of pregnancy, classified elsewhere655.70,655.71,655.73 Decreased fetal movements affecting management of mother unspecified as
to episode of care655.80,655.81,655.83 Other known or suspected fetal abnormality655.90,655.91,655.93 Unspecified fetal abnormality656.00,656.01,656.03 Fetal-maternal hemorrhage656.30,656.31,656.33 Fetal distress656.40,656.41,656.43 Intrauterine death666.00 Postpartum hemorrhage, third-stage, unspecified as to episode of care or not
applicable666.02 Postpartum hemorrhage, third-stage, delivered with mention of postpartum
complication666.04 Postpartum hemorrhage, third-stage, postpartum condition or complication
666.10 Other immediate postpartum hemorrhage, unspecified as to episode of care
or not applicable 666.12 Other immediate postpartum hemorrhage, delivered with mention of
postpartum complication666.14 Other immediate postpartum hemorrhage, postpartum condition or
complication666.20 Delayed and secondary postpartum hemorrhage666.22 Delayed and secondary postpartum hemorrhage delivered with mention of
postpartum complication666.24 Delayed and secondary postpartum hemorrhage postpartum condition or
complication668.10-668.14 Cardiac complications668.80-668.84 Other complications of anesthesia or other sedation in labor and delivery
668.90-668.94 Unspecified complication of anesthesia or other sedation in labor and
delivery
669.10-669.14 Shock during or following labor and delivery669.20-669.24 Maternal hypotension syndrome669.30-669.32 Acute renal failure following labor and delivery669.34 postpartum condition or complication669.40-669.44 Other complications of obstetrical surgery and procedures669.80-669.84 Other complications of delivery669.90-669.94 Unspecified complication of labor and delivery673.20-673.24 Obstetrical blood-clot embolism728.9 Unspecified disorders of muscle, ligament, and fascia729.82 Cramp of limb 729.89 Other musculoskeletal symptoms referable to limbs753.12 Polycystic kidney unspecified type753.13 Polycystic kidney autosomal dominant760.0 Maternal hypertensive disorders760.1 Maternal renal and urinary tract diseases 760.4 Maternal nutrition disorders760.71 Influences affecting fetus; alcohol760.8 Other specified maternal conditions affecting fetus or newborn
86 MAGNESIUM (LCD)
Medicare A Medical Policy April 16, 2006
MAGNESIUM
763.81-763.84 Other specified complications of labor and delivery affecting fetus or
newborn, abnormality in fetal heart rate or rhythm763.89 Unspecified complication of labor and delivery affecting fetus or newborn
763.9 Unspecified complication of labor and delivery affecting fetus or newborn
779.32 Bilious vomiting in newborn779.33 Other vomiting in newborn780.01-780.02 Coma780.09 Other alterations of consciousness780.2 Syncope and collapse780.31 Febrile convulsions (simple), unspecified780.32 Complex febrile convulsions780.39 Convulsions780.71 Chronic fatigue syndrome780.79 Malaise and fatigue781.0 Abnormal involuntary movements781.7 Tetany783.0 Anorexia783.21-783.22 Abnormal loss of weight783.3 Feeding difficulties and mismanagement783.9 Other symptoms concerning nutrition, metabolism, and development785.0 Tachycardia, unspecified785.50-785.51 Cardiogenic shock; shock unspecified785.59 Shock, other787.04 Bilious emesis787.91 Diarrhea790.6 Other abnormal blood chemistry794.31 Abnormal electrocardiogram794.4 Abnormal kidney test796.2 Elevated blood pressure reading without diagnosis of hypertension799.4 Cachexia958.4 Traumatic shock995.23 Unspecified adverse effect of insulin995.29 Unspecified adverse effect of other drug, medicinal and biological substance
996.81 Complications of transplanted kidney996.86 Complications of transplanted pancreas997.1 Cardiac complications998.0 Postoperative shock998.9 Unspecified complication of procedure, not elsewhere classified999.9 Other and unspecified complications of medical care, not elsewhere
classified, dialysisV23.0-V23.9 Supervision of high-risk pregnancy V42.0 Kidney replaced by transplantV42.1 Heart replaced by transplantV42.7 Liver replaced by transplantV42.83 Pancreas replaced by transplantV56.0 Extracorporeal dialysisV56.8 Other dialysisV58.11-V58.12 Chemotherapy, (cis-platinum)V58.69 Long term (current) use of other medications (high risk)
Reviewed: April 2013
87 MAGNESIUM (LCD)
National Coverage Decision November 25, 2002
CPT: 82272 Blood occult peroxidaseCPT: G0394 Blood Occult Test (e.g., guaiac), feces, for single determination for colorectal
neoplasm (e.g., patient was provided three cards or single triple card for
consecutive collection)
003.0 Salmonella gastroenteritis003.1 Salmonella septicemia004.0-004.9 Shigellosis005.0-005.9 Other food poisoning (bacterial)006.0-006.9 Amebiasis 007.0-007.9 Other protozoal intestinal diseases008.41-008.49 Intestinal infections due to other specified bacteria009.0-009.3 Ill-defined intestinal infections014.00-014.86 Tuberculosis of intestines, peritoneum, and mesenteric glands
040.2 Whipple's disease095.2 Syphilitic peritonitis095.3 Syphilis of liver098.0 Gonococcal infection, acute, lower genitourinary tract098.7 Gonococcal Infection anus and rectum 098.84 Gonococcal endocarditis123.0-123.9 Other cestode infection124 Trichinosis127.0-127.9 Other intestinal helminthiases139.8 Late effects of other and unspecified infectious and parasitic diseases
150.0-157.9 Malignant neoplasm of digestive organisms159.0-159.9 Malignant neoplasm of other and ill-defined sites within the digestive organs
and peritoneum 176.3 Kaposi's sarcoma, gastrointestinal sites197.4-197.5 Secondary malignant neoplasm of intestines197.8 Secondary malignant neoplasm of other digestive organs and spleen199.0 Disseminated malignant neoplasm204.00-204.92 Lymphoid leukemia205.00-208.92 Leukemia (Myeloid, Monocytic, Other or Unspecified type)209.00-209.03 Benign carcinoid tumors of the small intestine209.10-209.17 Benign carcinoid tumors of the appendix, large intestine and rectum209.40-209.43 Malignant carcinoid tumors of the small intestine209.50-209.57 Malignant carcinoid tumors of the appendix, large intestine and rectum
209.70 Secondary neuroendocrine tumor, unspecified site209.71 Secondary neuroendocrine tumor of distant lymph nodes209.72 Secondary neuroendocrine tumor of liver209.73 Secondary neuroendocrine tumor of bone209.74 Secondary neuroendocrine tumor of peritoneum209.75 Secondary Merkel cell carcinoma
209.79 Secondary neuroendocrine tumor of other sites
211.0-211.9 Benign neoplasm of other parts of digestive system
228.04 Hemangioma of intra-abdominal structures
230.2-230.9 Carcinoma in situ of digestive organs235.2 Neoplasm of uncertain behavior of stomach, intestines and rectum235.5 Neoplasm of uncertain behavior of other and unspecified digestive organs
BLOOD, OCCULT; FECES SCREENING
Frequency Limitation: See "Frequency Test List" for specifics.
88 OCCULT BLOOD (NCD)
National Coverage Decision November 25, 2002
BLOOD, OCCULT; FECES SCREENING
239.0 Neoplasm of unspecified nature, digestive system280.0-280.9 Iron deficiency anemias284.2 Myelophthisis285.0-285.9 Other and unspecified anemias286.0-286.9 Coagulation defects287.0-287.39 Allergic purpura; qualitative platelet defects; other non-thrombocytopenic
purpuras; primary thrombocytopenia287.41 Posttransfusion purpura287.49 Other secondary thrombocytopenia287.5-287.9 Thrombocytopenia, unspecified; other specified and unspecified hemorrhagic
conditions338.3 Neoplasm related pain (acute)(chronic)448.0 Hereditary hemorrhagic telangiectasia 455.0-455.8 Hemorrhoids456.0-456.21 Esophageal varices with or without mention of bleeding530.10-535.71 Diseases of esophagus, stomach, and duodenum536.2 Persistent vomiting536.8-536.9 Dyspepsia and other specified and unspecified functional disorders of the
stomach537.0-537.4 Other disorders of stomach and duodenum537.82-537.83 Angiodysplasia of stomach and duodenum537.84 Dieulatoy lesion (hemorrhagic) of stomach and duodenum537.89 Other specified disorders of the stomach and duodenum555.0-558.9 Non-infectious enteritis and colitis560.0-560.2 Intestinal obstruction: intussusceptions, paralytic ileus, volvulus560.3 Impaction of intestine, unspecified560.31 Gallstone ileus560.32 Fecal impaction560.39 Other impaction of intestine560.81-560.89, 560.9 Other and unspecified intestinal obstruction562.10-562.13 Diverticulosis/diverticulitis of colon564.00-564.9 Functional digestive disorders, not elsewhere classified565.0-565.1 Anal fissure 569.0 Anal and rectal polyp569.1 Rectal prolapse569.3 Hemorrhage of rectum and anus569.41-569.49 Other specified disorders of rectum and anus569.82-569.83 Ulceration and perforation of intestine 569.84-569.85 Angiodysplasia of intestine with or without mention of hemorrhage569.86 Dieulafoy lesion (hemorrhagic) of intestine569.87 Vomiting of fecal matter571.0-571.9 Chronic liver disease and cirrhosis577.0-577.9 Diseases of the pancreas578.0-578.9 Gastrointestinal hemorrhage579.0 Celiac disease579.8 Other specified intestinal malabsorption596.1 Intestinovesical fistula617.5 Endometriosis of intestine780.71 Chronic fatigue syndrome780.72 Functional quadriplegia780.79 Other malaise and fatigue783.0 Anorexia
89 OCCULT BLOOD (NCD)
National Coverage Decision November 25, 2002
BLOOD, OCCULT; FECES SCREENING
783.21 Abnormal loss of weight787.01-787.03 Nausea and vomiting787.04 Bilious emesis787.1 Heartburn787.20-787.29 Dysphagia787.7 Abnormal feces787.91 Diarrhea
787.99 Other symptoms involving digestive system789.00-789.09 Abdominal pain789.30-789.39 Abdominal or pelvic swelling, mass, or lump789.40-789.49 Abdominal rigidity789.51 Malignant Ascites789.59 Other Ascites789.60-789.69 Abdominal tenderness789.7 Colic790.92 Abdominal coagulation profile
792.1 Nonspecific abnormal findings in stool contents793.6 Nonspecific abnormal findings on radiological and other794.8 Nonspecific abnormal results of function studies, liver863.0-863.90 Injury to gastrointestinal tract863.91-863.95, 863.99 Injury to pancreas
864.00-864.09 Injury to liver without mention of open wound into cavity864.11-864.19 Injury to liver with open wound into cavity866.00-866.03 Injury to kidney without mention of open wound into cavity
866.10-866.13 Injury to kidney with open wound into cavity902.0-902.9 Injury to blood vessels of abdomen and pelvis926.11-926.19 Crushing injury of trunk, other specified sites926.8 Crushing injury of trunk, multiple sites926.9 Crushing injury of trunk, unspecified site995.20 Unspecified adverse effect of unspecified drug, medicinal and biological
substance995.24 Failed moderate sedation during procedure964.2 Poisoning by agents primarily affecting blood constituents, anticoagulants
V10.00-V10.09 Personal history of malignant neoplasm, gastrointestinal tractV12.00 Personal history of unspecified infectious and parasitic diseaseV12.72 Personal history of colonic polypsV58.61 Long term (current) use of anticoagulantsV58.63-V58.66 Long-term (current) drug useV58.69 Long term (current) use of other medicationsV67.51 Following treatment with high risk medication, not elsewhere specifiedV76.51 ** Screening for malignant neoplasm of the colon. **This screening is only
allowed once every 365 days with this code. If additional Occult Blood tests
are performed they must be diagnostic or must have an ABN for frequency.
Reviewed: April 2013
90 OCCULT BLOOD (NCD)
National Coverage Decision November 25, 2002
CPT: 84153 Prostate Specific Antigen; Total
185 Malignant neoplasm of prostate188.5 Malignant neoplasm of bladder neck196.5 Secondary malignant neoplasm, lymph nodes inguinal region and lower limb
196.6 Secondary malignant neoplasm, intrapelvic lymph nodes196.8 Secondary malignant neoplasm, lymph nodes of multiple sites198.5 Secondary malignant neoplasm, bone and bone marrow198.82 Secondary malignant neoplasm, genital organs233.4 Carcinoma in situ, prostate236.5 Neoplasm of uncertain behavior of prostate239.5 Neoplasm of unspecified nature, other genitourinary organs596.0 Bladder neck obstruction599.60 Urinary obstruction, unspecified599.69 Urinary obstruction, not elsewhere classified599.70-599.72 Hematuria600.00 Hypertrophy (benign) of prostate without urinary obstruction and other lower
urinary tract (LUTS)600.01 Benign prostate hypertrophy with urinary obstruction600.10 Nodular prostate without urinary obstruction600.11 Nodular prostate with urinary obstruction600.21 Benign localized hyperplasia of prostate with urinary obstruction and other
lower urinary tract symptoms (LUTS)601.9 Unspecified prostatitis602.9 Unspecified disorder of prostate788.20 Retention of urine, unspecified788.21 Incomplete bladder emptying788.30 Urinary incontinence, unspecified788.41 Urinary frequency788.43 Nocturia788.62 Slowing of urinary stream788.63-788.65 Urgency of urination790.93 Elevated prostate specific antigen793.6, 793.7 Non-specific abnormal result of radiologic examination, evidence of
malignancy794.9 Bone scan evidence of malignancyV10.46 Personal history of malignant neoplasm; prostateV76.44 ** Screening for malignant neoplasm of the prostate. **This screening is only
covered for men over 50 years of age once every 365 days with this code. If
additional PSA tests are performed they must be diagnostic or must have an
ABN for frequency.
Reviewed: April 2013
PROSTATE SPECIFIC ANTIGEN (PSA)
Frequency Limitation: See "Frequency Test List" for specifics.
91 PSA (NCD)
National Coverage Decision November 25, 2002
CPT: 85610 Prothrombin Time
002.0-002.9 Typhoid and paratyphoid
003.0-003.9 Other Salmonella infections
038.9 Unspecified Septicemia
042 Human Immunodeficiency virus (HIV) disease
060.0-060.9 Yellow fever
065.0-065.9 Arthropod-borne hemorrhagic fever
070.0-070.9 Viral hepatitis
075 Infectious mononucleosis
078.6 Hemorrhagic nephrosonephritis
078.7 Arenaviral hemorrhagic fever
084.8 Blackwater fever
120.0 Schistosomiasis121.1 Clonorchiasis121.3 Fascioliasis124 Trichinosis134.2 Hirudiniasis135 Sarcoidosis152.0-152.9 Malignant neoplasm of small intestine, including duodenum155.0-155.2 Malignant neoplasm of liver and intrahepatic bile ducts156.0-156.9 Malignant neoplasm of gallbladder and extrahepatic bile ducts157.0-157.9 Malignant neoplasm of pancreas188.0-189.9 Malignant neoplasm of bladder, kidney, and other and unspecified urinary
organs
197.7 Secondary malignant neoplasm, liver198.0 Secondary malignant neoplasm, kidney198.1 Secondary malignant neoplasm, other urinary organs200.00-200.88 Lymphosarcoma and reticulosarcoma202.00-202.98 Other malignant neoplasms of lymphoid and histiocytic tissue209.20-209.29 Malignant carcinoid tumors of other and unspecified sites209.70 Secondary neuroendocrine tumor, unspecified site209.71 Secondary neuroendocrine tumor of distant lymph nodes209.72 Secondary neuroendocrine tumor of liver209.73 Secondary neuroendocrine tumor of bone209.74 Secondary neuroendocrine tumor of peritoneum209.75 Secondary Merkel cell carcinoma209.79 Secondary neuroendocrine tumor of other sites223.0-223.9 Benign neoplasm of kidney and other urinary organs238.4 Polycythemia vera238.5 Histocytic and mast cells - neoplasm of uncertain behavior238.6 Plasma cells - neoplasm of uncertain behavior238.71-238.79 Other lymphatic and hematopoietic tissues239.4 Neoplasm of unspecified nature, bladder239.5 Neoplasm of unspecified nature, other genitourinary organs239.9 Neoplasm of unspecified nature, site unspecified246.3 Hemorrhage and infarction of thyroid249.40-249.41 Secondary diabetes mellitus with renal manifestations250.40-250.43 Diabetic with renal manifestations263.0-263.9 Other and unspecified protein/calorie malnutrition
PROTHROMBIN TIME
92 PT (NCD)
National Coverage Decision November 25, 2002
PROTHROMBIN TIME
269.0 Deficiency of Vitamin K269.2 Unspecified vitamin deficiency273.0-273.9 Disorders of plasma protein metabolism275.01 Hereditary hemochromatosis275.02 Hemochromatosis due to repeated red blood cell transfusions275.03 Other hemochromatosis275.09 Other disorders of iron metabolism277.1 Disorders of porphyrin metabolism277.30-277.39 Amyloidosis280.0 Iron deficiency anemia, secondary to blood loss - chronic280.9 Iron deficiency anemia, unspecified281.0 Pernicious anemia281.1 Other Vitamin B12 Deficiency Anemia, NEC281.9 Unspecified Deficiency Anemia, NOS285.0 Sideroblastic anemia285.1 Acute posthemorrhagic anemia286.0-286.9 Coagulation defects287.0-287.39 Allergic purpura; qualitative platelet defects; other non-thrombocytopenic
purpuras; primary thrombocytopenia287.41 Posttransfusion purpura287.49 Other secondary thrombocytopenia287.5-287.9 Thrombocytopenia, unspecified; other specified and unspecified hemorrhagic
conditions289.81 Primary hypercoagulable state290.40-290.43 Vascular dementia325 Phlebitis and thrombophlebitis of intracranial venous sinuses342.90-342.92 Hemiplegia NOS360.43 Hemophthalmos, except current injury362.18 Retinal vasculitis362.30-362.37 Retinal vascular occlusion362.43 Hemorrhagic detachment of retinal pigment epithelium362.81 Retinal hemorrhage363.61-363.72 Choroidal hemorrhage and rupture, detachment368.9 Unspecified Visual Disturbances372.72 Conjunctival hemorrhage374.81 Hemorrhage of eyelid376.32 Orbital hemorrhage377.42 Hemorrhage in optic nerve sheaths377.53 Disorders of optic chiasm associated with vascular disorders377.62 Disorders of visual pathways associated with vascular disorders377.72 Disorders of visual cortex associated with vascular disorders379.23 Vitreous hemorrhage380.31 Hematoma of auricle or pinna
386.2 Vertigo of central origin
386.50 Labyrinthine dysfunction, unspecified394.0-394.9 Diseases of the mitral valve395.0 Rheumatic aortic stenosis 395.2 Rheumatic aortic stenosis with insufficiency396.0-396.9 Diseases of mitral and aortic valves397.0-397.9 Diseases of other endocardial structures398.0-398.99 Other rheumatic heart disease
93 PT (NCD)
National Coverage Decision November 25, 2002
PROTHROMBIN TIME
403.01, 403.11 403.91 Hypertensive chronic kidney disease, with chronic kidney disease stage V or
end stage renal disease404.02, 404.12 404.92 Hypertensive heart and chronic kidney disease without heart failure and with
chronic kidney disease stage V or end stage renal disease410.00-410.92 Acute myocardial infarction 411.1 Intermediate coronary syndrome411.81 Coronary occlusion without myocardial infarction411.89 Other acute and subacute forms of ischemic heart disease413.0-413.9 Angina pectoris414.00-414.07 Coronary atherosclerosis414.3 Coronary atherosclerosis due to lipid rich plaque414.4 Coronary atherosclerosis due to calcified coronary lesion414.8 Other specified forms of chronic ischemic heart disease414.9 Chronic ischemic heart disease, unspecified415.0-415.19 Acute pulmonary heart disease
416.9 Chronic pulmonary heart disease, unspecified423.0 Hemopericardium424.0 Mitral valve disorders424.1 Aortic valve disorder424.90 Endocarditis, valve unspecified, unspecified cause425.0, 425.11, 425.18
425.2 - 425.9-425.9
Cardiomyopathy
427.0-427.9 Cardiac dysrhythmias428.0-428.9 Heart failure429.0-429.4 Ill-defined descriptions and complications of heart disease429.79 Other certain sequelae of myocardial infarction, not elsewhere classified
430 Subarachnoid hemorrhage 431 Intracerebral hemorrhage432.0-432.9 Other and unspecified intracranial hemorrhage433.00-433.91 Occlusion and stenosis of precerebral arteries434.00-434.91 Occlusion of cerebral arteries435.0-435.9 Transient cerebral ischemia436 Acute, but ill-defined cerebrovascular disease437.0 Cerebral atherosclerosis437.1 Other generalized ischemic cerebrovascular disease437.6 Nonpyogenic thrombosis of intracranial venous sinus440.0-440.9 Atherosclerosis441.0-441.9 Aortic aneurysm and dissection443.0-443.9 Other peripheral vascular disease444.01, 444.09,
444.1 - 444.9
Arterial embolism and thrombosis
447.1 Stricture of artery447.2 Rupture of artery447.6 Arteritis, unspecified448.0 Hereditary hemorrhagic telangiectasia448.9 Other and unspecified capillary diseases451.0-451.9 Phlebitis and thrombophlebitis 452 Portal vein thrombosis453.0-453.9 Other venous embolism and thrombosis455.2 Internal hemorrhoids with other complication455.5 External hemorrhoids with other complication455.8 Unspecified hemorrhoids with other complication
94 PT (NCD)
National Coverage Decision November 25, 2002
PROTHROMBIN TIME
456.0-456.1 Esophageal varices456.8 Varices of other sites459.0 Hemorrhage, unspecified459.10-459.19 Postphlebitis syndrome459.2 Compression of vein459.81 Venous (peripheral) insufficiency, unspecified459.89 Other, other specified disorders of circulatory system511.81 Malignant pleural effusion511.89 Other specified forms of effusion except tuberculous514 Pulmonary congestion and hypostasis530.7 Gastroesophageal laceration - hemorrhage syndrome530.82 Esophageal hemorrhage530.86 Infection of esophagostomy530.87 Mechanical complication of esophagostomy531.00-535.71 Gastric ulcer, duodenal ulcer, peptic ulcer, gastrojejunal ulcer, gastritis and
duodenitis555.0-555.9 Regional enteritis556.0-556.9 Ulcerative colitis557.0-557.9 Vascular insufficiency of intestine562.02-562.03 Diverticulosis of small intestine with hemorrhage562.10 Diverticulosis of colon w/o hemorrhage562.11 Diverticulitis of colon w/o hemorrhage562.12 Diverticulitis of colon with hemorrhage562.13 Diverticulitis of colon with hemorrhage568.81 Hemoperitoneum (nontraumatic)569.3 Hemorrhage of rectum and anus571.0-571.9 Chronic liver disease and cirrhosis572.2 Hepatic Coma572.4 Hepatorenal syndrome572.8 Other sequelae of chronic liver disease573.1-573.9 Hepatitis in viral diseases, other and unspecified disorder of liver576.0-576.9 Other disorders of Biliary tract577.0 Acute pancreatitis578.0-578.9 Gastrointestinal hemorrhage579.0-579.9 Intestinal Malabsorption581.0-581.9 Nephrotic Syndrome583.9 Nephritis, with unspecified pathological lesion in kidney584.5-584.9 Acute Renal Failure585.4-585.9 Chronic kidney disease586 Renal failure, unspecified593.81-593.89 Other specified disorders of kidney and ureter596.7 Hemorrhage into bladder wall596.81 Infection of cystostomy596.82 Mechanical complication of cystostomy596.83 Other complication of cystostomy596.89 Other specified disorders of bladder599.70-599.72 Hematuria607.82 Vascular disorders of penis608.83 Vascular disorders of male genital organs611.89 Other specified disorders of breast 620.7 Hematoma of broad ligament621.4 Hematometra
95 PT (NCD)
National Coverage Decision November 25, 2002
PROTHROMBIN TIME
622.8 Other specified noninflammatory disorders of cervix
623.6 Vaginal hematoma
623.8 Other specified noninflammatory disorders of the vagina
624.5 Hematoma of vulva
626.2-626.9 Abnormal bleeding from female genital tract627.0 Premenopausal menorrhagia627.1 Postmenopausal bleeding629.0 Hematocele female, not classified elsewhere632 Missed abortion634.10-634.12 Spontaneous abortion, complicated by excessive hemorrhage635.10-635.12 Legally induced abortion, complicated by delayed or excessive hemorrhage
636.10-636.12 Illegally induced abortion, complicated by delayed or excessive hemorrhage
637.10-637.12 Abortion unspecified, complicated by delayed or excessive hemorrhage
638.1 Failed attempted abortion, complicated by delayed or excessive hemorrhage
639.1 Delayed or excessive hemorrhage following abortion and ectopic and molar
pregnancies639.6 Complications following abortion and ectopic and molar pregnancies with
embolism640.00-640.93 Hemorrhage in early pregnancy641.00-641.93 Antepartum hemorrhage, abruptio placentae, and placenta previa642.00-642.94 Hypertension complicating pregnancy, childbirth, and the puerperium646.70-646.73 Liver disorders in pregnancy649.30-649.34 Coagulation defects complicating pregnancy, childbirth, or the puerperium,
unspecified as to episode of care or not applicable649.50-649.53 Spotting complicating pregnancy, unspecified as to episode of care or not
applicable656.00-656.03 Fetal maternal hemorrhage658.40-658.43 Infection of amniotic cavity666.00-666.34 Postpartum hemorrhage671.20-671.94 Venous complications in pregnancy and the puerperium except legs, vulva
and perineum673.00-673.84 Obstetrical pulmonary embolism674.30-674.34 Other complications of obstetrical surgical wounds713.2 Arthropathy associated with hematological disorders713.6 Arthropathy associated with hypersensitivity reaction719.15 Hemarthrosis pelvic region and thigh719.16 Lower Leg719.19 Multiple sites729.5 Pain in limb729.81 Swelling of limb733.10 Pathologic fracture, unspecified site746.00-746.9 Other Congenital anomalies of heart762.1 Other forms of placental separation and hemorrhage767.0,767.11 Birth trauma, subdural and cerebral hemorrhage and injury to scalp767.8 Other specified birth trauma770.3 Pulmonary hemorrhage772.0-772.9 Fetal and neonatal hemorrhage774.6 Unspecified fetal and neonatal jaundice776.0-776.9 Hemorrhagic disease of the newborn780.2 Syncope and collapse782.3 Edema
96 PT (NCD)
National Coverage Decision November 25, 2002
PROTHROMBIN TIME
782.4 Jaundice, unspecified, not of newborn782.7 Spontaneous ecchymosis784.7 Epistaxis784.8 Hemorrhage from throat785.4 Gangrene785.50 Shock without mention of trauma786.05 Shortness of breath786.30 Hemoptysis, unspecified786.31 Acute idiopathic pulmonary hemorrhage in infants (AIPHI)786.39 Other hemoptysis786.50 Chest pain, unspecified786.51 Precordial pain786.59 Chest pain, other789.00-789.09 Abdominal pain789.7 Colic789.1 Hepatomegaly789.51 Malignant Ascites789.59 Other Ascites790.92 Abnormal coagulation profile790.94 Euthyroid sick syndrome791.2 Hemoglobinuria794.8 Abnormal Liver Function Study800.00-800.99 Fracture of vault of skull801.00-801.99 Fracture of base of skull802.20-802.9 Fracture of face bones803.00-803.99 Other and unqualified skull fractures804.00-804.99 Multiple fractures involving skull or face with other bones805.00-806.9 Fracture, vertebral column807.00-807.09 Fractures of rib(s), closed807.10-807.19 Fracture of rib(s), open808.8-808.9 Unspecified fracture of pelvis809.0-809.1 Ill-defined fractures of bones of trunk810.00-810.13 Fracture of clavicle811.00-811.19 Fracture of scapula812.00-812.59 Fracture of humerus813.10-813.18 Fracture of radius and ulna, upper end, open813.30-813.33 Shaft, open813.50-813.54 Lower end, open813.90-813.93 Fracture unspecified part, open819.0-819.1 Multiple fractures involving upper both upper limbs, closed and open820.00-821.39 Fracture of neck of femur823.00-823.92 Fracture of tibia and fibula827.0-829.1 Other multiple lower limb852.00-853.19 Subarachnoid subdural, and extradural hemorrhage, following injury, Other
and specified intracranial hemorrhage following injury860.0-860.5 Traumatic pneumothorax and hemothorax861.00-861.32 Injury to heart and lung862.0-862.9 Injury to other and unspecified intrathoracic organs863.0-863.90 Injury to gastrointestinal tract863.91-863.95 &
863.99
Injury to Pancreas
864.00-864.19 Injury to liver
97 PT (NCD)
National Coverage Decision November 25, 2002
PROTHROMBIN TIME
865.00-865.19 Injury to spleen866.00-866.13 Injury to kidney867.0-867.9 Injury to pelvic organs868.00-868.19 Injury to other intra-abdominal organs869.0-869.1 Internal injury to unspecified or ill defined organs900.00-900.9 Injury to blood vessels of head and neck901.0-901.9 Injury to blood vessels of the thorax902.0-902.9 Injury to blood vessels of the abdomen and pelvis903.00-903.9 Injury to blood vessels of upper extremity904.0-904.9 Injury to blood vessels of lower extremity and unspecified sites920-924.9 Contusion with intact skin surface925.1-929.9 Crushing injury
958.2 Secondary and recurrent hemorrhage959.9 Injury, unspecified site964.0-964.9 Poisoning by agents primarily affecting blood constituents980.0-980.9 Toxic effect of alcohol981 Toxic effect of petroleum products982.0-982.8 Toxic effects of solvents other than petroleum-based987.0-987.9 Toxic effect of other gases, fumes or vapors989.0-989.9 Toxic effect of other substances chiefly non-medicinal as to source995.20 Unspecified adverse effect of unspecified drug, medicinal and biological
substance995.21 Arthus phenomenon995.24 Failed moderate sedation during procedure995.27 Other drug allergy995.29 Unspecified adverse effect of other drug, medicinal and biological substance
996.82 Complication of transplanted liver997.02 Iatrogenic cerebrovascular infarction or hemorrhage997.41 Retained cholelithiasis following cholecystectomy997.49 Other digestive system complications998.11-998.12 Hemorrhage or hematoma complicating a procedure999.2 Other vascular complications999.80 Transfusion reaction, unspecified999.83 Hemolytic transfusion reaction, incompatibility unspecified999.84 Acute hemolytic transfusion reaction, incompatibility unspecified999.85 Delayed hemolytic transfusion reaction, incompatibility unspecified999.89 Other transfusion reactionV08 Asymptomatic HIV infectionV12.1 History of nutritional deficiencyV12.3 Personal history of diseases of blood and blood-forming organsV12.50-V12.55, V12.59 Personal history of transient ischemic attack, cerebral infarction, or
pulmonary embolism without residual deficitsV15.1 Personal history of surgery to heart and great vesselsV15.21 Personal history of undergoing in utero procedure during pregnancyV15.22 Personal history of undergoing in utero procedure while a fetusV15.29 Personal history of surgery of other major organsV42.0 Kidney replaced by transplantV42.1 Heart replaced by transplantV42.2 Heart valve replaced by transplantV42.6 Lung replaced by transplantV42.7 Liver replaced by transplantV42.81-V42.89 Other specified organ or tissue replaced by transplant
98 PT (NCD)
National Coverage Decision November 25, 2002
PROTHROMBIN TIME
V43.21, V43.22 Heart replaced by other meansV43.3 Heart valve replaced by other meansV43.4 Blood vessel replaced by other meansV58.2 Transfusion of blood productsV58.61 Long term (current) use of anticoagulantsV58.83 Encounter for therapeutic drug monitoring
Reviewed: April 2013
99 PT (NCD)
National Coverage Decision November 25, 2002
CPT: 85730 Partial Thromboplastin Time (PTT)
002.0-002.9 Typhoid and paratyphoid
003.0-003.9 Other Salmonella infections
038.9 Unspecified Septicemia
042 Human immunodeficiency virus (HIV) disease
060.0-060.9 Yellow fever
065.0-065.9 Arthropod borne hemorrhagic fever
070.0-070.9 Viral Hepatitis
075 Infectious mononucleosis
078.6 Hemorrhagic nephrosonephritis
078.7 Arenaviral hemorrhagic fever
120.0 Schistosomiasis haematobium
121.1 Clonorchiasis121.3 Fascioliasis124 Trichinosis135 Sarcoidosis155.0-155.2 Malignant neoplasm of liver and intrahepatic bile ducts197.7 Malignant neoplasm of liver, specified as secondary238.4 Polycythemia vera238.71-238.79 Other lymphatic and hemapoietic tissues239.9 Neoplasm of unspecified nature, site unspecified246.3 Hemorrhage and infarction of thyroid249.40-249.41 Secondary diabetes mellitus with renal manifestations250.40-250.43 Diabetic with renal manifestations269.0 Deficiency of Vitamin K273.0-273.9 Disorders of plasma protein metabolism275.01 Hereditary hemochromatosis275.02 Hemochromatosis due to repeated red blood cell transfusions275.03 Other hemochromatosis275.09 Other disorders of iron metabolism275.1 Disorders of copper metabolism275.2 Disorders of magnesium metabolism275.3 Disorders of phosphorus metabolism275.40-275.49 Disorders of calcium metabolism275.5 Hungry bone syndrome275.8-275.9 Other specified disorders of mineral metabolism, and unspecified disorder of
mineral metabolism277.1 Disorders of porphyrin metabolism277.30-277.39 Amyloisodosis285.1 Acute posthemorrhagic anemia286.0 Congenital factor VIII disorder - Hemophilia A286.1 Congenital factor IX disorder - Hemophilia B286.2-286.3 Other congenital factor deficiencies286.4 von Willebrand's disease286.52 Acquired hemophilia286.53 Antiphospholipid antibody with hemorrhagic disorder286.59 Other hemorrhagic disorder due to intrinsic circulating anticoagulants,
antibodies, or inhibitors286.6 Defibrination syndrome
PARTIAL THROMBOPLASTIN TIME
100 PTT (NCD)
National Coverage Decision November 25, 2002
PARTIAL THROMBOPLASTIN TIME
286.7 Acquired coagulation factor deficiency286.9 Other and unspecified coagulation defects287.0-287.39 Allergic purpura; qualitative platelet defects; other non-thrombocytopenic
purpuras; primary thrombocytopenia287.41 Posttransfusion purpura287.49 Other secondary thrombocytopenia287.5-287.9 Thrombocytopenia, unspecified; other specified and unspecified hemorrhagic
conditions289.0 Polycythemia, secondary289.81 Primary hypercoagulable state325 Phlebitis and thrombophlebitis of intracranial venous sinuses360.43 Hemophthalmos, except current injury362.30-362.37 Retinal vascular occlusion362.43 Hemorrhagic detachment of retinal pigment epithelium362.81 Retinal hemorrhage363.61-363.63 Choroidal hemorrhage363.72 Choroidal detachment368.9 Unspecified Visual Disturbances372.72 Conjunctive hemorrhage374.81 Hemorrhage of eyelid376.32 Orbital hemorrhage377.42 Hemorrhage in optic nerve sheaths379.23 Vitreous hemorrhage380.31 Hematoma of auricle or pinna403.01, 403.11,
03.91
Hypertensive chronic kidney disease, with chronic kidney disease stage V or
end stage renal disease404.02, 404.12,
404.92
Hypertensive heart and chronic kidney disease without heart failure and with
chronic kidney disease stage V or end stage renal disease410.00-410.92 Acute myocardial infarction423.0 Hemopericardium427.31 Atrial fibrillation427.9 Cardiac dysrhythmias, unspecified428.0 Congestive heart failure, unspecified429.79 Mural thrombus430-432.9 Cerebral hemorrhage433.00-433.91 Occlusion and stenosis of precerebral arteries434.00-434.91 Occlusion of cerebral arteries435.9 Focal neurologic deficit444.01, 444.09,
444.1 - 444.9
Arterial embolism and thrombosis
446.6 Thrombotic microangiopathy447.2 Rupture of artery448.0 Hereditary Hemorrhagic telangiectasia451.0-451.9 Phlebitis and thrombophlebitis453.0-453.9 Other Venous emboli and thrombosis456.0 Esophageal varices with bleeding456.1 Esophageal varices without bleeding456.8 Varices of other sites459.89 Ecchymosis530.7 Gastroesophageal laceration - hemorrhage syndrome530.82 Esophageal hemorrhage
101 PTT (NCD)
National Coverage Decision November 25, 2002
PARTIAL THROMBOPLASTIN TIME
531.00-535.71 Gastric ulcer, duodenal ulcer, peptic ulcer, gastrojejunal ulcer, gastritis and
duodenitis537.83 Angiodysplasia of stomach and duodenum with hemorrhage537.84 Dielulafoy lesion (Hemorrhagic) of stomach and duodenum556.0-557.9 Hemorrhagic bowel disease562.02-562.03 Diverticulosis of small intestine with hemorrhage562.12 Diverticulosis of colon with hemorrhage562.13 Diverticulitis of colon with hemorrhage568.81 Hemoperitoneum (nontraumatic)569.3 Hemorrhage of rectum and anus570 Acute and subacute necrosis of liver571.0-573.9 Liver disease (in place of specific codes listed)576.0-576.9 Biliary tract disorders577.0 Acute pancreatitis578.0-578.9 Gastrointestinal Hemorrhage579.0-579.9 Malabsorption581.0-581.9 Nephrotic Syndrome583.9 Nephritis, with unspecified pathological lesion in kidney584.5-584.9 Acute Renal Failure585.4 Chronic kidney disease, Stage IV (severe)585.5 Chronic kidney disease, Stage V585.6 End stage renal disease585.9 Chronic kidney disease, unspecified586 Renal failure593.81-593.89 Other disorders of kidney and ureter, with hemorrhage596.7 Hemorrhage into bladder wall596.81 Infection of cystostomy596.82 Mechanical complication of cystostomy596.83 Other complication of cystostomy596.89 Other specified disorders of bladder
599.70-599.72 Hematuria
607.82 Penile hemorrhage
608.83 Vascular disorders of male genital organs
611.89 Other specified disorders of Breast
620.7 Hemorrhage of broad ligament621.4 Hematometra622.8 Other specified disorders of cervix, with hemorrhage623.6 Vaginal hematoma623.8 Other specified diseases of the vagina, with hemorrhage624.5 Hematoma of vulva626.6 Metrorrhagia626.7 Postcoital bleeding627.0 Premenopausal bleeding627.1 Postmenopausal bleeding629.0 Hematocele female not elsewhere classified632 Missed abortion634.00-634.92 Spontaneous abortion635.10-635.12 Legally induced abortion, complicated by delayed or excessive hemorrhage
636.10-636.12 Illegally induced abortion, complicated by delayed or excessive hemorrhage
637.10-637.12 Abortion unspecified, complicated by delayed or excessive hemorrhage
638.1 Failed attempt abortion, complicated by delayed or excessive hemorrhage
102 PTT (NCD)
National Coverage Decision November 25, 2002
PARTIAL THROMBOPLASTIN TIME
639.1 Delayed or excessive hemorrhage following abortion and ectopic and molar
pregnancies639.6 Complications following abortion and ectopic and molar pregnancies,
embolism640.00-640.93 Hemorrhage in early pregnancy641.00-641.93 Antepartum hemorrhage642.00-642.94 Hypertension complicating pregnancy, childbirth, and the puerperium646.70-646.73 Liver disorders in pregnancy649.30-649.34 Coagulation defects complicating pregnancy, childbirth, or the puerperium,
unspecified as to episode of care or not applicable649.50-649.53 Spotting complicating pregnancy, unspecified as to episode of care or not
applicable656.00-656.03 Fetal maternal hemorrhage658.40-658.43 Infection of amniotic cavity666.00-666.34 Postpartum hemorrhage671.20-671.54 Phlebitis in pregnancy673.00-673.84 Obstetrical pulmonary embolus674.30-674.34 Other complications of surgical wounds, with hemorrhage710.0 Systemic Lupus erythematosus713.2 Arthropathy associated with hematologic disorders (note: may not be used
without indicating associated condition first)713.6 Arthropathy associated with Henoch Schonlein (note: may not be used
without indicating associated condition first)719.10-719.19 Hemarthrosis729.5 Leg pain/calf pain729.81 Swelling of limb733.10-733.19 Pathologic fracture associated with fat embolism762.1 Other forms of placental separation with hemorrhage (affecting newborn code-
do not assign to mother's record)764.90-764.99 Fetal intrauterine growth retardation767.0,767.11 Subdural and cerebral hemorrhage767.8 Other specified birth trauma, with hemorrhage770.3 Fetal and newborn pulmonary hemorrhage772.0-772.9 Fetal and neonatal hemorrhage774.0-774.7 Other perinatal jaundice776.0-776.9 Hemorrhagic disease of the newborn780.2 Syncope782.4 Jaundice, unspecified, not of newborn782.7 Spontaneous ecchymoses Petechiae784.7 Epistaxis784.8 Hemorrhage from throat785.4 Gangrene785.50 Shock786.05 Shortness of breath786.30 Hemoptysis, unspecified786.31 Acute idiopathic pulmonary hemorrhage in infants (AIPHI)786.39 Other hemoptysis786.50 Chest pain, unspecified786.59 Chest pain 789.00-789.09 Abdominal pain789.7 Colic790.92 Abnormal coagulation profile
103 PTT (NCD)
National Coverage Decision November 25, 2002
PARTIAL THROMBOPLASTIN TIME
800.00-800.99 Fracture of vault of skull801.00-801.99 Fracture of base of skull802.20-802.9 Fracture of face bones803.00-803.99 Other fracture, skull804.00-804.99 Multiple fractures, skull805.00-806.9 Fracture, vertebral column807.00-807.09 Fractures of rib(s), closed807.10-807.19 Fractures of rib(s), open808.8-808.9 Fracture of pelvis809.0-809.1 Fracture of trunk810.00-810.13 Fracture of clavicle811.00-811.19 Fracture of scapula812.00-812.59 Fracture of humerus813.10-813.18 Fracture of radius and ulna, upper end, open813.30-813.33 Fracture of radius and ulna, shaft, open813.50-813.54 Fracture of radius and ulna, lower end, open813.90-813.93 Fracture of radius and ulna, unspecified part, open819.0-819.1 Multiple fractures 820.00-821.39 Femur823.00-823.92 Tibia and fibula827.0-829.1 Other multiple lower limb852.00-853.19 Subarachnoid subdural, and extradural hemorrhage, following injury, Other
and specified intracranial hemorrhage following injury860.0-860.5 Traumatic pneumothorax and hemothorax861.00-861.32 Injury to heart and lung862.0-862.9 Injury to other and unspecified intrathoracic organs863.0-863.99 Injury to gastrointestinal tract864.00-864.19 Injury to liver865.00-865.19 Injury to spleen866.00-866.13 Injury to kidney867.0-867.9 Injury to pelvic organs868.00-868.19 Injury to other intra-abdominal organs
869.0-869.1 Internal injury to unspecified or ill defined organs900.00-900.9 Injury to blood vessels of head and neck901.0-901.9 Injury to blood vessels of the thorax902.0-902.9 Injury to blood vessels of the abdomen and pelvis903.00-903.9 Injury to blood vessels of upper extremity904.0-904.9 Injury to blood vessels of lower extremity and unspecified sites920-924.9 Contusion with intact skin surface925.1-929.9 Crushing injury958.2 Secondary and recurrent hemorrhage959.9 Injury, unspecified site964.2 Poisoning by anticoagulants964.5 Poisoning by anticoagulant antagonists964.7 Poisoning by natural blood and blood products980.0 Toxic effects of alcohol989.5 Snake venom995.20 Unspecified adverse effect of unspecified drug, medicinal and biological
substance995.21 Arthus phenomenon995.24 Failed moderate sedation during procedure995.27 Other drug allergy
104 PTT (NCD)
National Coverage Decision November 25, 2002
PARTIAL THROMBOPLASTIN TIME
995.29 Unspecified adverse effect of other drug, medicinal and biological substance
996.70-996.79 Other complications of internal prosthetic device997.02 Iatrogenic cerebrovascular infarction or hemorrhage998.11 Hemorrhage or hematoma complicating a procedure998.12 Hematoma complicating a procedure999.2 Other vascular complications of medical careV12.3 Personal history of diseases of blood and blood forming organsV58.2 Admission for Transfusion of blood productsV58.61 Long term (current use) of anticoagulantsV58.83 Encounter for therapeutic drug monitoring
Reviewed: April 2013
105 PTT (NCD)
National Coverage Decision November 25, 2002
CPT: 84436 Thyroxine; total
CPT: 84439 Thyroxine; free
CPT: 84443 Thyroid stimulating hormone (TSH)
CPT: 84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)
017.50-017.56 Tuberculosis of the thyroid gland
183.0 Malignant neoplasm of ovary
193 Malignant neoplasm of thyroid gland
194.8 Malignant neoplasm of other endocrine glands and related structures, other
198.89 Secondary malignant neoplasm of the thyroid
220 Benign neoplasm of ovary
226 Benign neoplasm of thyroid gland
227.3 Benign neoplasm of pituitary gland and craniopharyngeal duct
234.8 Carcinoma in situ of other and unspecified sites237.4 Neoplasm of uncertain behavior of other and unspecified endocrine glands
239.7 Neoplasm of unspecified nature, thyroid gland240.0-240.9 Goiter specified and unspecified241.0-241.9 Nontoxic nodular goiter242.00-242.91 Thyrotoxicosis with or without goiter243 Congenital hypothyroidism244.0-244.9 Acquired hypothyroidism245.0-245.9 Thyroiditis246.0-246.9 Other disorders of thyroid249.40-249.41 Secondary diabetes mellitus with renal manifestations250.00-250.93 Diabetes mellitus252.1 Hypoparathyroidism253.1 Other and unspecified anterior pituitary hyper function253.2 Panhypopituitarism253.3 Pituitary dwarfism253.4 Other anterior pituitary disorders253.7 Iatrogenic pituitary disorders255.2 Adrenogenital disorders255.41 Glucocorticoid deficiency255.42 Mineralocorticoid deficiency256.31-256.39 Ovarian failure257.2 Testicular hypofunction258.0-258.9 Polyglandular dysfunction262 Malnutrition, severe263.0-263.9 Malnutrition, other and unspecified266.0 Ariboflavinosis272.0 Pure hypercholesterolemia272.2 Mixed hyperlipidemia272.4 Other and unspecified hyperlipidemia275.40-275.49 Calcium disorders275.5 Hungry bone syndrome276.0 Hyposmolality and/or hypernatremia276.1 Hyposmolality and/or hyponatremia278.3 Hypercarotenemia279.41-279.49 Autoimmune disorder, not classified elsewhere
THYROID TESTING
106 THYROID (NCD)
National Coverage Decision November 25, 2002
THYROID TESTING
281.0 Pernicious anemia281.9 Unspecified deficiency anemia283.0 Autoimmune hemolytic anemia285.9 Anemia, unspecified290.0 Senile dementia, uncomplicated290.10-290.13 Presenile dementia290.20-290.21 Senile dementia with delusional or depressive features290.3 Senile dementia with delirium293.0-293.1 Delirium293.81-293.89 Transient organic mental disorders294.8 Other specified organic brain syndromes296.00-296.99 Affective psychoses297.0 Paranoid state, simple297.1 Paranoia297.9 Unspecified paranoid state298.3 Acute paranoid reaction300.00-300.09 Anxiety states307.9 Agitation-other and unspecified special symptoms or syndromes, not
elsewhere classified310.1 Organic personality syndrome311 Depressive disorder, not elsewhere classified327.00-327.8 Other organic sleep disorders331.0, 331.11,
331.19, 331.2
Alzheimer's, pick's disease, Senile degeneration of brain
331.83 Mild cognitive impairment, so stated333.1 Essential and other specified forms of tremor333.99 Other extrapyramidal diseases and abnormal movement disorders354.0 Carpal Tunnel syndrome356.9 Idiopathic peripheral neuropathy, unspecified polyneuropathy358.1 Myasthenic syndromes in diseases classified elsewhere359.5 Myopathy in endocrine diseases classified elsewhere359.9 Myopathy, unspecified368.2 Diplopia372.71 Conjunctival hyperemia372.73 Conjunctival edema374.41 Lid retraction or lag374.82 Eyelid edema376.21 Thyrotoxic exophthalmos376.22 Exophthalmic ophthalmoplegia376.30-376.31 Exophthalmic conditions, unspecified and constant376.33-376.34 Orbital edema or congestion, intermittent exophthalmos378.50-378.55 Paralytic strabismus401.0-401.9 Essential hypertension403.00-403.91 Hypertensive renal disease404.00-404.93 Hypertensive heart and renal disease423.9 Unspecified disease of pericardium425.7 Nutritional and metabolic cardiomyopathy427.0 Paroxysmal supraventricular tachycardia427.2 Paroxysmal tachycardia, unspecified427.31 Atrial fibrillation427.89 Other specified cardiac dysrhythmia427.9 Cardiac dysrhythmia, unspecified
107 THYROID (NCD)
National Coverage Decision November 25, 2002
THYROID TESTING
428.0 Congestive heart failure428.1 Left heart failure429.3 Cardiomegaly511.9 Unspecified pleural effusion518.81 Acute respiratory failure529.8 Other specified conditions of the tongue560.1 Paralytic ileus564.00-564.09 Constipation564.7 Megacolon, other than Hirschsprung's568.82 Peritoneal effusion (chronic)625.3 Dysmenorrhea626.0-626.2 Disorders of menstruation626.4 Irregular menstrual cycle648.10-648.14 Other current conditions in the mother, classifiable elsewhere, but
complicating pregnancy, childbirth, or the puerperium, thyroid dysfunction
676.20-676.24 Engorgement of breast associated with childbirth and disorders of lactation
698.9 Unspecified pruritic disorder
701.1 Keratoderma, acquired (dry skin)703.8 Other specified diseases of nail (Brittle nails)704.00-704.09 Alopecia709.01 Vitiligo710.0-710.9 Diffuse disease of connective tissue728.2 Muscle wasting728.87 Muscle weakness728.9 Unspecified disorder of muscle, ligament, and fascia729.1 Myalgia and myositis, unspecified729.82 Musculoskeletal cramp730.30-730.39 Periostitis without osteomyelitis733.02 Idiopathic osteoporosis733.09 Osteoporosis, drug induced750.15 Macroglossia, congenital759.2 Anomaly of other endocrine glands780.01 Coma780.02 Transient alteration of awareness780.09 Alteration of consciousness, other 780.50-780.52 Insomnia780.60-780.66 Fever and other physiologic disturbances of temperature regulation780.71-780.79 Malaise and fatigue780.8 Hyperhidrosis780.93 Memory Loss780.94 Early satiety780.96 Generalized pain780.97 Altered mental status780.99 Other general symptoms (hyperthermia)781.0 Abnormal involuntary movements781.3 Lack of coordination, ataxia782.0 Disturbance of skin sensation782.3 Localized edema782.8 Changes in skin texture782.9 Other symptoms involving skin and integumentary tissues783.0 Anorexia783.1 Abnormal weight gain
108 THYROID (NCD)
National Coverage Decision November 25, 2002
THYROID TESTING
783.21 Abnormal loss of weight783.6 Polyphagia784.1 Throat pain784.42 Dysphonia784.43 Hypernasality784.44 Hyponasality784.49 Voice disturbance784.51 Dysarthria784.59 Other speech disturbance785.0 Tachycardia, unspecified785.1 Palpitations785.9 Other symptoms involving cardiovascular system786.09 Other symptoms involving respiratory system786.1 Stridor787.20-787.29 Dysphagia787.91-787.99 Other symptoms involving digestive system789.51 Malignant Ascites789.59 Other Ascites793.99 Other nonspecific abnormal findings on radiological and other examinations
of body structure794.5 Thyroid, abnormal scan or uptake796.1 Other nonspecific abnormal findings, abnormal reflex799.21 Nervousness799.22 Irritability799.23 Impulsiveness799.24 Emotional lability799.25 Demoralization and apathy799.29 Other signs and symptoms involving emotional state990 Effects of radiation, unspecifiedV10.87 Personal history of malignant neoplasm of the thyroidV10.88 Personal history of malignant neoplasm of other endocrine glandV10.91 Personal history of malignant neuroendocrine tumorV12.21 Personal history of gestational diabetesV12.29 Personal history of other endocrine, metabolic, and immunity disorders
V58.69 Long tern (current) use of other medicationsV67.00-V67.9 Follow-up examination
Reviewed: April 2013
109 THYROID (NCD)
Medicare A Medical Policy October 1, 2005
CPT: 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin,
ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any
number of these constituents; with microscopyCPT: 81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin,
ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any
number of these constituents; with microscopyCPT: 81002 Urinalysis without microscopy, non-automated
CPT: 81003 Urinalysis without microscopy, automated
CPT: 81005 Urinalysis; qualitative or semiquantitative, except immunoassays
CPT: 81007 Urinalysis; bacteria screen, by non-culture technique, commercial kit (specify
type)CPT: 81015 Urinalysis; microscopic only
CPT: 81020 Urinalysis; two or three glass test
016.00-016.96 Tuberculosis of the genitourinary system
038.0 - 038.9 Septicemia
041.00 Streptococcus infection in conditions classified elsewhere & of unspecified
site, Streptococcus unspecified041.01 Streptococcus infection in conditions classified elsewhere & of unspecified
site, Streptococcus GROUP A041.02 Streptococcus infection in conditions classified elsewhere & of unspecified
site, Streptococcus GROUP B041.03 Streptococcus infection in conditions classified elsewhere & of unspecified
site, Streptococcus GROUP C041.04 Streptococcus infection in conditions classified elsewhere & of unspecified
site, Streptococcus GROUP D [Enterococcus]041.05 Streptococcus infection in conditions classified elsewhere & of unspecified
site, Streptococcus GROUP G041.09 Streptococcus infection in conditions classified elsewhere & of unspecified
site, other Streptococcus041.10 Staphylococcus infection in conditions classified elsewhere & of unspecified
site, Unspecified041.11 Staphylococcus infection - Methicillin susceptible Staphylococcus aureus
(MSSA)041.12 Staphylococcus infection - Methicillin Resistant Staphylococcus aureus
(MRSA)041.19 Staphylococcus infection in conditions classified elsewhere & of unspecified
site, other Staphylococcus041.2 Pneumococcus infection in conditions classified elsewhere & of unspecified
site041.3 Klebsiella Pneumoniae041.41 Shiga toxin-producing Escherichia Coli [E. Coli] (STEC)041.42 Other specified Shiga toxin-producing Escherichia Coli [E. Coli] (STEC)
041.43 Shiga toxin-producing Escherichia Coli [E. Coli] (STEC), unspecified041.49 Other and unspecified Shiga toxin-producing Escherichia Coli [E. Coli] 041.5 Hemophilus Influenzae (H. Influenzae) infection in conditions classified
041.6 Proteus (Mirabilis) (Morganii) infection in conditions classified elsewhere & of
unspecified site041.7 Pseudomonas infection in conditions classified elsewhere & of unspecified
site
URINALYSIS (UA)
110 URINALYSIS (LCD)
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URINALYSIS (UA)
041.81 Other specified bacterial infections in conditions classified elsewhere & of
unspecified site, Mycoplasma041.82 Other specified bacterial infections in conditions classified elsewhere & of
unspecified site, Bacteroides Fragilis041.83 Other specified bacterial infections in conditions classified elsewhere & of
unspecified site, Clostridium Perfringens041.84 Other specified bacterial infections in conditions classified elsewhere & of
unspecified site, other anaerobes041.85 Other specified bacterial infections in conditions classified elsewhere & of
unspecified site, other gram-negative organisms041.86 Helicobacter Pylori (H. Pylori)041.89 Bacterial infection unspecified in conditions classified elsewhere & of
unspecified site, other specified bacteria041.9 Bacterial infection unspecified in conditions classified elsewhere & of
unspecified site054.10-054.19 Genital herpes070.0 - 070.59 Viral hepatitis 070.70 Unspecified viral hepatitis C without hepatic coma070.71 Unspecified viral hepatitis C with hepatic coma072.0 Mumps orchitis 078.11 Condyloma acuminatum 078.88 Other specified diseases due to chlamydia 079.81-079.89 Other specified viral and chlamydial infection 079.98 Unspecified chlamydial infection 087.0 - 087.1 Relapsing fever 095.4 Syphilis of kidney098.0 Gonococcal infection, acute, lower genitourinary tract 098.10-098.19 Gonococcal infection, acute, upper genitourinary tract 098.2 Gonococcal infection, chronic, of lower genitourinary tract098.30-098.39 Gonococcal infection, chronic, of upper genitourinary tract
098.89 Other Gonococcal infection of other specified sites 099.3 Reiter's disease 099.40 - 099.49 Nonspecified urethritis 099.53 - 099.54 Other venereal diseases due to Chlamydia trachomatis 100.0 Leptospiral icterohemorrhagica 102.0 - 102.9 Yaws 112.1 Candidasis of vulva and vagina 112.2 Candidasis of other urogenital sites125.0 - 125.1 Filarial infection and dracontiasis131.00 - 131.03 Urogenital trichomoniasis 135 Sarcoidosis185 Malignant neoplasm of prostate 186.0, 186.9 Malignant neoplasm of testis 187.1 Malignant neoplasm of prepuce 187.1 Malignant neoplasm of penis and other male genital organs
187.2 Malignant neoplasm of glans penis 187.3 Malignant neoplasm of body of penis187.5 Malignant neoplasm of epididymis187.6 Malignant neoplasm of spermatic cord 187.7 Malignant neoplasm of scrotum187.8 Malignant neoplasm of other specified sites of male genital organs 188.0 - 188.9 Malignant neoplasm of bladder
111 URINALYSIS (LCD)
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URINALYSIS (UA)
189.0 - 189.9 Malignant neoplasm of kidney and other and unspecified urinary organs
198.0, 198.1 Secondary malignant neoplasm of kidney and other urinary organs 203.00 Multiple Myeloma without mention of having achieved remission203.01 Multiple Myeloma in remission203.02 Multiple Myeloma in relapse222.2 Benign neoplasm of prostate 223.0 - 223.3 Benign neoplasm of kidney and other urinary organs 223.81 - 223.89 Benign neoplasm of urethra and other urinary organs233.4 Carcinoma in situ of prostate233.7 Carcinoma in situ of bladder 233.9 Carcinoma in situ and other unspecified urinary organs 236.5 Neoplasm of uncertain behavior of prostate 236.7 Neoplasm of uncertain behavior of bladder236.90 - 236.99 Neoplasm of uncertain behavior of other and unspecified urinary organs
249.00-249.91 Secondary Diabetes Mellitus, with or without various manifestations250.00 - 250.93 Diabetes mellitus 253.5 - 253.6 Diabetes insipidus and other disorders of neurohypophysis 271.4 Renal glycosuria 272.2 - 272.4 Mixed and other unspecified hyperlipidemia 273.0 - 273.8 Disorders of plasma protein metabolism274.00-274.03 Gouty arthropathy274.10 - 274.19 Gouty nephropathy 275.01 Hereditary hemochromatosis275.02 Hemochromatosis due to repeated red blood cell transfusions275.03 Other hemochromatosis275.09 Other disorders of iron metabolism275.42 Hypercalcemia 276.0 Hyperosmolality and/or hypernatremia276.1 Hyposmolality and/or hyponatremia276.2 Acidosis276.3 Alkalosis276.4 Mixed acid-base balance disorder276.50 Volume depletion, unspecified276.51 Dehydration276.52 Hypovolemia276.61 Transfusion associated circulatory overload276.69 Other fluid overload276.8 Hypopotassemia276.9 Electrolyte & fluid disorders not elsewhere classified277.00 - 277.09 Cystic Fibrosis (use 5th digit to specify)277.1 - 277.5 Amyloidosis/disorders of bilirubin excretion 277.88 Tumor lysis syndrome282.60 - 282.69 Sickle-cell anemia 283.11 Hemolytic-uremic syndrome283.2 Hemoglobinuria due to hemolysis from external causes287.41 Posttransfusion purpura287.49 Other secondary thrombocytopenia306.53 Psychogenic Dysuria310.1 Personality change due to conditions classified elsewhere344.61 Cauda equina syndrome with neurogenic bladder 401.0 - 405.99 Hypertensive disease421.0 - 421.9 Acute and subacute endocarditis
112 URINALYSIS (LCD)
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URINALYSIS (UA)
428.0 Congestive heart failure446.0 - 446.7 Polyarteritis nodosa and allied conditions 447.3 - 447.6 Other disorders of arteries and arterioles 456.4 Scrotal varices (varicocele) 457.0 - 457.1 Postmastectomy lymphedema and other lymphedema 570 Acute and subacute necrosis of liver 571.40 - 571.49 Chronic hepatitis 571.5 - 571.8 Chronic and other cirrhosis of the liver572.2 Hepatic encephalopathy573.0 - 573.3 Other disorders of liver 580.0 - 583.9 Nephritis, nephrotic syndrome, and nephrosis584.5 - 584.9 Acute kidney failure 585.9 Chronic renal failure 586 Renal failure, unspecified 587 Renal sclerosis588.0 Renal osteodystrophy588.1 - 588.89 Disorders resulting from impaired renal function 589.0 - 589.9 Small kidney, unknown cause590.00 - 590.9 Infection of kidney591 Hydronephrosis 592.0 - 592.9 Calculus of kidney and ureter 593.0 - 593.6 Other disorders of kidney and ureter 593.70 - 593.73 Vesicoureteral reflux593.81 - 593.89 Other specified disorders of kidney and ureter593.9 Unspecified disorder of kidney and ureter 594.0 - 594.9 Calculus of lower urinary tract595.0 - 595.9 Cystitis 596.0 - 596.4 Other disorders of bladder 596.51 - 596.59 Other functional disorders of bladder 596.6 - 596.9 Rupture of bladder, nontraumatic; hemorrhage into bladder wall; other
specified disorders of bladder597.0 Urethral abscess 597.80 - 597.89 Other and unspecified urethritis 598.00 - 598.01 Urethral stricture due to infection 598.1 - 598.9 Urethral stricture 599.0 Urinary Tract Infection, unspecified site (UTI)599.1 - 599.69 Other disorders of urethra and urinary tract599.70 Hematuria599.71 Gross hematuria599.72 Microscopic hematuria599.9 Unspecified disorders of urethra and urinary tract600.01 Hypertophy (benign) of prostate with urinary obstruction & other lower
urinary tract symptoms (LUTS)600.11 Nodular prostate with urinary obstruction600.21 Benign localized hyperplasia of prostate with urinary obstruction and other
lower urinary tract symptoms (LUTS)600.91 Hyperplasia of prostate, unspecified, with urinary obstruction & other lower
urinary symptoms (LUTS)601.0 - 601.9 Inflammatory diseases of prostate602.0 - 602.9 Other disorders of prostate603.0 - 603.9 Hydrocele604.0 Orchitis and epididymitis
113 URINALYSIS (LCD)
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URINALYSIS (UA)
604.90-604.91 Other orchitis, epididymitis and epididymoorchitis, without mention of
abscess605 Redundant prepuce and phimosis606.1 Oligospermia606.9 Male infertility, unspecified 607.1 Balanoposthitis607.81 Balanitis xerotica obliterans607.84 Impotence of organic origin607.89 Other specified disorders of penis608.0 Seminal vesiculitis608.1 Spermatocele 608.23 Torsion of appendix testis608.24 Torsion of appendix epididymis608.83 Vascular disorders of male genital organs608.89 Other disorders of male genital organs 608.9 Unspecified disorders of male genital organs616.10 - 616.11 Vaginitis and vulvovaginitis618.00 - 618.09 Genital prolapse 619.0 - 619.9 Fistula involving female genital tract625.0 Dyspareunia625.6 Stress incontinence, female 625.70 - 625.79 Vulvodynia625.9 Unspecified symptom associated with female genital organs628.9 Infertility, female of unspecified origin 629.31 Erosion of implanted vaginal mesh and other prosthetic materials to
surrounding organ or tissues629.32 Exposure of implanted vaginal mesh ant other prosthetic materials into
634.00 - 634.32 Spontaneous abortion with complications635.00 - 635.32 Legally induced abortion with complications636.00 - 636.32 Illegally induced abortion with complications637.00 - 637.32 Unspecified abortion with complications638.0 - 638.3 Failed attempted abortion with complications639.0 - 639.3 Complications following abortion and ectopic and molar pregnancies642.00 - 642.94 Benign essential hypertension complicating pregnancy, childbirth and the
puerperium646.10 Edema or excessive weight gain in pregnancy, unspecified as to episode of
care646.11 Edema or excessive weight gain in pregnancy, with delivery, with or without
mention of antepartum complication646.12 Edema or excessive weight gain in pregnancy, with delivery, with mention of
postpartum complication646.13 Antepartum edema or excessive weight gain646.14 Postpartum edema or excessive weight gain646.20 Unspecified renal disease in pregnancy, unspecified as to episode of care
646.21 Unspecified renal disease in pregnancy, with delivery646.22 Unspecified renal disease in pregnancy, with delivery, with mention of
postpartum complication646.23 Unspecified antepartum renal disease646.24 Unspecified postpartum renal disease646.50 Asymptomatic bacteriuria in pregnancy, unspecified as to episode of care
646.51 Asymptomatic bacteriuria in pregnancy, with delivery
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646.52 Asymptomatic bacteriuria in pregnancy, with delivery, with mention of
postpartum complication646.53 Antepartum asymptomatic bacteriuria646.54 Postpartum asymptomatic bacteriuria646.60 - 646.64 Infection of genitourinary tract in pregnancy 647.10 - 647.14 Infections and parasitic conditions in mother, Gonorrhea 648.00 - 648.04 Other current conditions in mother, Diabetes mellitus 648.80 - 648.84 Other abnormalities in shape or position of gravid uterus and of neighboring
structures 654.40 - 654.44 Other abnormalities in shape or position of gravid uterus and of neighboring
structures
658.40 Infection of amniotic cavity unspecified as to episode of care658.41 Infection of amniotic cavity delivered658.43 Infection of amniotic cavity antepartum659.20 Unspecified type maternal pyrexia during labor unspecified as to episode of
care659.21 Unspecified type maternal pyrexia during labor delivered659.23 Unspecified type maternal pyrexia antepartum659.30 Generalized infection during labor unspecified as to episode of care659.31 Generalized infection during labor delivered659.33 Generalized infection during labor antepartum664.80 Other specified trauma to perineum and vulva unspecified as to episode of
care in pregnancy664.81 Other specified trauma to perineum and vulva with delivery664.84 Other specified trauma to perineum and vulva postpartum664.90 Unspecified trauma to perineum and vulva unspecified as to episode of care
in pregnancy664.91 Unspecified trauma to perineum and vulva with delivery664.94 Unspecified trauma to perineum and vulva postpartum665.40 High vaginal laceration unspecified as to episode of care in pregnancy
665.41 High vaginal laceration with delivery665.44 High vaginal laceration postpartum665.50 Other injury to pelvic organs unspecified as to episode of care in pregnancy
665.51 Other injury to pelvic organs with delivery665.54 Other injury to pelvic organs postpartum665.80 Other specified obstetrical trauma unspecified as to episode of care665.81 Other specified obstetrical trauma with delivery665.82 Other specified obstetrical trauma delivered with postpartum condition or
complication665.83 Other specified obstetrical trauma antepartum665.84 Other specified obstetrical trauma postpartum669.30 - 669.34 Acute kidney failure following labor and delivery 670.00 Major puerperal infection, unspecified, unspecified as to episode of care
670.02 Major puerperal infection, unspecified, delivered, with postpartum
complication670.04 Major puerperal infection, unspecified, postpartum condition or complication
670.20-670.24 Puerperal sepsis670.80-670.84 Other major puerperal infection672.00 - 672.04 Pyrexia of unknown origin during the puerperium 710.0 - 710.4 Diffuse diseases of connective tissue710.9 Unspecified diffuse connective tissue disease
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711.00 - 711.09 Pyogenic arthritis 714.0 - 714.9 Rheumatoid arthritis 719.40 - 719.49 Pain in joint 724.2 Lumbago724.5 Backache, unspecified 752.51 Undescended testis 753.0 Renal agenesis and dysgenesis 753.10 - 753.19 Cystic kidney disease 753.3 - 753.9 Other anomalies of urinary system780.02 Transient Alteration of awareness780.09 Alteration of consciousness, other780.2 Syncope and collapse780.33 Post traumatic seizures780.4 Dizziness and giddiness780.60-780.65 Fever and other physiologic disturbances of temperature regulation780.66 Febrile nonhemolytic transfusion reaction780.79 Malaise and fatigue780.91 Fussy Infant (baby)780.97 Altered Mental Status782.3 Edema783.5 Polydipsia785.59 Other shock without mention of trauma 787.01 Nausea with vomiting787.03 Vomiting Alone787.91 Diarrhea788.0 - 788.1 Renal colic/dysuria 788.20 - 788.29 Retention of urine 788.30 - 788.39 Incontinence of urine788.41 - 788.43 Frequency of urination and polyuria 788.5 Oliguria and anuria 788.61 - 788.69 Other abnormality of urination788.7 Urethral discharge/extravasation of urine/ other symptoms involving urinary
system 788.8 Extravasation of urine788.91 Functional urinary incontinence788.99 Other symptoms involving urinary system789.00 - 789.09 Abdominal Pain (specify site)789.51 Ascites, Malignant790.21 Abnormal glucose tolerance test790.22 Impaired glucose tolerance test790.29 Other abnormal glucose790.7 Bacteremia 790.93 Elevated PSA 790.95 Elevated C-reactive protein791.0 - 791.9 Nonspecific findings on examination of urine 793.5 - 793.6 Abnormal findings on radiological and other examinations of genitourinary
organs, abdominal area, including retroperitoneum 794.4 Nonspecific abnormal results of function study of kidney795.79 Other and unspecified nonspecific immunological findings, e.g., abnormal
ANA test796.2 Elevated blood pressure reading without diagnosis of hypertension 799.21 Nervousness
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799.22 Irritability799.23 Impulsiveness799.24 Emotional lability799.59 Other signs and symptoms involving cognition806.5 Open fracture of lumbar spine with spinal cord injury806.70 Open fracture of sacrum and coccyx with unspecified spinal cord injury
806.71 Open fracture of sacrum and coccyx with complete cauda equina lesion
808.0 Closed fracture of acetabulum808.1 Open fracture of acetabulum808.2 Closed fracture of pubis808.3 Open fracture of pubis808.41 Closed fracture of ilium808.42 Closed fracture of ischium808.43 Multiple closed pelvic fractures with disruption of pelvic circle808.44 Multiple closed pelvic fractures without disruption of pelvic circle808.49 Closed fracture of other specified part of pelvis808.51 Open fracture of ilium808.52 Open fracture of ischium808.53 Multiple open pelvic fractures with disruption of pelvic circle808.54 Multiple open pelvic fractures without disruption of pelvic circle808.59 Open fracture of other specified part of pelvis808.9 Unspecified open fracture of pelvis866.00 - 866.13 Injury to kidney 867.0 - 867.3 Injury to bladder and urethra 867.6 Injury to other specified pelvic organs, without mention of open wound into
cavity 867.7 Injury to other specified pelvic organs with open wound into cavity867.8 Injury to other specified pelvic organ without open wound into cavity867.9 Injury to unspecified pelvic organ with open wound into cavity868.00 Injury to unspecified intra-abdominal organ without open wound into cavity
868.09 Injury to other and multiple intra-abdominal organs without open wound into
cavity868.10 Injury to unspecified intra-abdominal organ with open wound into cavity
868.19 Injury to other and multiple intra-abdominal organs with open wound into
cavity869.0 Internal injury to unspecified or ill-defined organs without open wound into
cavity
869.1 Internal injury to unspecified or ill-defined organs with open wound into
cavity876.1 Open wound of back complicated878.0 Open wound of genital organs (external) including traumatic amputation
879.3 Open wound of abdominal wall anterior complicated879.5 Open wound of abdominal wall lateral complicated879.7 Open wound of other and unspecified parts of trunk complicated879.8 Open wound(s) (multiple) of unspecified site(s) without complication879.9 Open wound(s) (multiple) of unspecified site(s) complicated922.1 - 922.33 Contusion of trunk (specify site)922.4 Contusion to genital organs 926.0 Crushing injury of external genitalia 926.11 Crushing injury of back926.12 Crushing injury of buttock
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926.19 Crushing injury of other specified sites of trunk926.8 Crushing injury to multiple sites of trunk927.00 Crushing injury of shoulder region928.00 Crushing injury of thigh928.01 Crushing injury of hip928.10 Crushing injury of lower leg928.8 Crushing injury of multiple sites of lower limb929.0 Crushing injury of multiple sites not elsewhere classified929.9 Crushing injury of unspecified site939.0 Foreign body in genitourinary tract, bladder and urethra 939.2 Foreign body in vulva and vagina939.3 Foreign body in penis939.9 Foreign body in unspecified site in genitourinary tract941.39 Full thickness skin loss due to burn (third degree nos) of multiple sites
(except with eye) of face head and neck941.49 Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple sites (except with eye) of face head and neck without loss of a body
part941.59 Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple sites (except eye) of face head and neck with loss of a body part
942.20 Blisters with epidermal loss due to burn (second degree) of unspecified site
of trunk942.22 Blisters with epidermal loss due to burn (second degree) of chest wall
excluding breast and nipple942.23 Blisters with epidermal loss due to burn (second degree) of abdominal wall
942.24 Blisters with epidermal loss due to burn (second degree) of back (any part)942.29 Blisters with epidermal loss due to burn (second degree) of other and
multiple sites of trunk942.30 Full thickness skin loss due to burn (third degree nos) of unspecified site of
trunk942.32 Full thickness skin loss due to burn (third degree nos) of chest wall excluding
breast and nipple942.33 Full thickness skin loss due to burn (third degree nos) of abdominal wall942.34 Full thickness skin loss due to burn (third degree nos) of back (any part)
942.39 Full thickness skin loss due to burn (third degree nos) of other and multiple
sites of trunk942.40 Deep necrosis of underlying tissues due to burn (deep third degree) of trunk
unspecified site without loss of body part942.42 Deep necrosis of underlying tissues due to burn (deep third degree) of chest
wall excluding breast and nipple without loss of chest wall942.43 Deep necrosis of underlying tissues due to burn (deep third degree) of
abdominal wall without loss of abdominal wall942.44 Deep necrosis of underlying tissues due to burn (deep third degree) of back
(any part) without loss of back942.49 Deep necrosis of underlying tissues due to burn (deep third degree) of other
and multiple sites of trunk without loss of body part942.50 Deep necrosis of underlying tissues due to burn (deep third degree) of
unspecified site of trunk with loss of body part942.52 Deep necrosis of underlying tissues due to burn (deep third degree) of chest
wall excluding breast and nipple with loss of chest wall942.53 Deep necrosis of underlying tissues due to burn (deep third degree) of
abdominal wall with loss of abdominal wall
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942.54 Deep necrosis of underlying tissues due to burn (deep third degree) of back
(any part) with loss of back942.59 Deep necrosis of underlying tissues due to burn (deep third degree) of other
and multiple sites of trunk with loss of a body part943.30 Full thickness skin loss due to burn (third degree nos) of unspecified site of
upper limb943.39 Full thickness skin loss due to burn (third degree nos) of multiple sites of
upper limb except wrist and hand943.40 Deep necrosis of underlying tissues due to burn (deep third degree) of
unspecified site of upper limb without loss of a body part943.49 Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple sites of upper limb except wrist and hand without loss of upper limb
943.50 Deep necrosis of underlying tissues due to burn (deep third degree) of
unspecified site of upper limb with loss of a body part943.59 Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple sites of upper limb except wrist and hand with loss of upper limb
946.2 Blisters with epidermal loss due to burn (second degree) of multiple specified
sites946.3 Full thickness skin loss due to burn (third degree burn nos) of multiple
specified sites946.4 Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple specified sites without loss of a body part946.5 Deep necrosis of underlying tissues due to burn (deep third degree) of
multiple specified sites with loss of a body part947.1 Burn of larynx trachea and lung947.2 Burn of esophagus947.3 Burn of gastrointestinal tract947.4 Burn of vagina and uterus947.8 Burn of other specified sites of internal organs948.21 Burn (any degree) involving 20-29 percent of body surface with third degree
burn of 10-19%948.22 Burn (any degree) involving 20-29 percent of body surface with third degree
burn of 20-29%948.30 Burn (any degree) involving 30-39 percent of body surface with third degree
burn of less than 10 percent or unspecified amount948.31 Burn (any degree) involving 30-39 percent of body surface with third degree
burn of 10-19%948.32 Burn (any degree) involving 30-39 percent of body surface with third degree
burn of 20-29%948.33 Burn (any degree) involving 30-39 percent of body surface with third degree
burn of 30-39%948.40 Burn (any degree) involving 40-49 percent of body surface with third degree
burn of less than 10 percent or unspecified amount948.41 Burn (any degree) involving 40-49 percent of body surface with third degree
burn of 10-19%948.42 Burn (any degree) involving 40-49 percent of body surface with third degree
burn of 20-29%948.43 Burn (any degree) involving 40-49 percent of body surface with third degree
burn of 30-39%948.44 Burn (any degree) involving 40-49 percent of body surface with third degree
burn of 40-49%
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948.50 Burn (any degree) involving 50-59 percent of body surface with third degree
burn of less than 10 percent or unspecified amount948.51 Burn (any degree) involving 50-59 percent of body surface with third degree
burn of 10-19%948.52 Burn (any degree) involving 50-59 percent of body surface with third degree
burn of 20-29%948.53 Burn (any degree) involving 50-59 percent of body surface with third degree
burn of 30-39%948.54 Burn (any degree) involving 50-59 percent of body surface with third degree
burn of 40-49%948.55 Burn (any degree) involving 50-59 percent of body surface with third degree
burn of 50-59%948.60 Burn (any degree) involving 60-69 percent of body surface with third degree
burn of less than 10 percent or unspecified amount948.61 Burn (any degree) involving 60-69 percent of body surface with third degree
burn of 10-19%948.62 Burn (any degree) involving 60-69 percent of body surface with third degree
burn of 20-29%948.63 Burn (any degree) involving 60-69 percent of body surface with third degree
burn of 30-39%948.64 Burn (any degree) involving 60-69 percent of body surface with third degree
burn of 40-49%948.65 Burn (any degree) involving 60-69 percent of body surface with third degree
burn of 50-59%948.66 Burn (any degree) involving 60-69 percent of body surface with third degree
burn of 60-69%948.70 Burn (any degree) involving 70-79 percent of body surface with third degree
burn of less than 10 percent or unspecified amount948.71 Burn (any degree) involving 70-79 percent of body surface with third degree
burn of 10-19%948.72 Burn (any degree) involving 70-79 percent of body surface with third degree
burn of 20-29%948.73 Burn (any degree) involving 70-79 percent of body surface with third degree
burn of 30-39%948.74 Burn (any degree) involving 70-79 percent of body surface with third degree
burn of 40-49%948.75 Burn (any degree) involving 70-79 percent of body surface with third degree
burn of 50-59%948.76 Burn (any degree) involving 70-79 percent of body surface with third degree
burn of 60-69%948.77 Burn (any degree) involving 70-79 percent of body surface with third degree
burn of 70-79%948.80 Burn (any degree) involving 80-89 percent of body surface with third degree
burn of less than 10 percent or unspecified amount948.81 Burn (any degree) involving 80-89 percent of body surface with third degree
burn of 10-19%948.82 Burn (any degree) involving 80-89 percent of body surface with third degree
burn of 20-29%948.83 Burn (any degree) involving 80-89 percent of body surface with third degree
burn of 30-39%948.84 Burn (any degree) involving 80-89 percent of body surface with third degree
burn of 40-49%
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948.85 Burn (any degree) involving 80-89 percent of body surface with third degree
burn of 50-59%948.86 Burn (any degree) involving 80-89 percent of body surface with third degree
burn of 60-69%948.87 Burn (any degree) involving 80-89 percent of body surface with third degree
burn of 70-79%948.88 Burn (any degree) involving 80-89 percent of body surface with third degree
burn of 80-89%948.90 Burn (any degree) involving 90 percent of body surface with third degree burn
of less than 10 percent or unspecified amount948.91 Burn (any degree) involving 90 percent of body surface with third degree burn
of 10-19%948.92 Burn (any degree) involving 90 percent of body surface with third degree burn
of 20-29%948.93 Burn (any degree) involving 90 percent of body surface with third degree burn
of 30-39%948.94 Burn (any degree) involving 90 percent of body surface with third degree burn
of 40-49%948.95 Burn (any degree) involving 90 percent of body surface with third degree burn
of 50-59%948.96 Burn (any degree) involving 90 percent of body surface with third degree burn
of 60-69%948.97 Burn (any degree) involving 90 percent of body surface with third degree burn
of 70-79%948.98 Burn (any degree) involving 90 percent of body surface with third degree burn
of 80-89%948.99 Burn (any degree) involving 90 percent of body surface with third degree burn
of 90% or more of body surface949.3 Full thickness skin loss due to burn (third degree nos) unspecified site949.4 Deep necrosis of underlying tissue due to burn (deep third degree)
unspecified site without loss of a body part949.5 Deep necrosis of underlying tissues due to burn (deep third degree
unspecified site with loss of a body part)958.5 Traumatic anuria 959.11 Other injury of chest wall959.12 Other injury of abdomen959.13 Fracture of corpus cavernosum penis959.14 Other injury of external genitals959.19 Other and unspecified injury of other sites of trunk961.2 Poisoning by heavy metal anti-infectives 963.1 Poisoning by antineoplastic and immuno-suppressive drugs 963.3 Poisoning by alkalizing agents 965.1 Poisoning by salicylates 992.0 - 992.8 Effects of heat and light 995.20 Unspecified adverse effect of unspecified drug, medicinal and biological
substance995.21 Arthus Phenomenon995.22 Unspecified adverse effect of anesthesia995.23 Unspecified adverse effect of insulin995.27 Other drug allergy995.29 Unspecified adverse effect of other drug, medicinal and biological substance
995.53 Child sexual abuse
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995.54 Child physical abuse995.59 Other child abuse and neglect996.30 - 996.39 Mechanical complication of genitourinary device, implant and g raft 996.62 Infection and inflammatory reaction due to other vascular device implant and
graft996.64 - 996.65 Infection and inflammatory reaction due to internal prosthetic device, implant
and graft996.76 Other complications due to genitourinary device implant and graft996.81 Complications of transplanted kidney 997.5 Urinary complications998.00 Postoperative shock, unspecified998.01 Postoperative shock, cardiogenic998.02 Postoperative shock, septic998.09 Postoperative shock, other998.2 Accidental puncture or laceration during a procedure 999.32 Bloodstream infection due to central venous catheter999.33 Local infection due to central venous catheter999.34 Acute infection following transfusion, infution, or injection of blood and blood
products999.60 ABO incompatibility reaction, unspecified
999.61 ABO incompatibility with hemolytic transfusion reaction not specified as
acute or delayed
999.62 ABO incompatibility with acute hemolytic transfusion reaction
999.63 ABO incompatibility with delayed hemolytic transfusion reaction
999.69 Other ABO incompatibility reaction
999.70 Rh incompatibility reaction, unspecified
999.71 Rh incompatibility with hemolytic transfusion reaction not specified as acute
or delayed
999.72 Rh incompatibility with acute hemolytic transfusion reaction
999.73 Rh incompatibility with delayed hemolytic transfusion reaction999.74 Other Rh incompatibility reaction999.75 Non-ABO incompatibility reaction, unspecified999.76 Non-ABO incompatibility with hemolytic transfusion reaction not specified as
acute or delayed999.77 Non-ABO incompatibility with acute hemolytic transfusion reaction999.78 Non-ABO incompatibility with delayed hemolytic transfusion reaction999.79 Other non-ABO incompatibility reaction999.80 Transfusion reaction, unspecified999.83 Hemolytic transfusion reaction, incompatibility unspecified999.84 Acute hemolytic transfusion reaction, incompatibility unspecified999.85 Delayed hemolytic transfusion reaction, incompatibility unspecified999.88 Complications of medical care, not elsewhere classified; other infusion
reaction 999.89 Complications of medical care, not elsewhere classified; other transfusion
reaction V10.46 Personal history of malignant neoplasm of prostate V10.50 - V10.59 Personal history of malignant neoplasm urinary organsV13.00 - V13.09 Personal history of other diseases urinary system V13.62 Personal history of other (corrected) congenital malformations of
genitourinary systemV15.51 Personal history of traumatic fractureV15.59 Personal history of other injury
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V21.0 - V21.9 Constitutional states in development V22.0 - V22.2 Normal pregnancy V23.0 - V23.7 Supervision of high-risk pregnancyV23.81 - V23.89 Other high risk pregnancy V23.9 Unspecified high-risk pregnancy V42.0 Persons with organs or tissue replaced by kidney transplant V44.50 - V44.59 Persons with cystostomy V44.6 Persons with other artificial opening of urinary tract V45.11 Renal dialysis statusV58.0 Radiotherapy V58.63 Long term (current) use of antiplatelets/antithromboticsV58.64 Long term (current) use of nonsteroidal anti-inflammatoriesV58.65 Long term (current) use of other medications V58.69 Long term (current) use of other medications V59.4 Kidney DonorsV67.51 Following completed treatment with high-risk medication, NECV87.01 -V87.2 Contact with and (suspected) exposure to hazardous metals, compounds or
chemicalsV90.83 Retained stone or crystalline fragments
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CPT: 87086 Culture, bacterial, quantitative, colony count, urine
CPT: 87088 Culture, bacterial; with isolation and presumptive identification of each
isolates, urineCPT: 87184 Susceptibility studies, antimicrobial agent; disk method, per plate (12 or fewer
agents)CPT: 87186 Susceptibility studies, antimicrobial agent; microdilution or agar dilution
(minimum inhibitory concentration (MIC) or breakpoint), each multi-
antimicrobial, per plate
003.1 Salmonella septicemia
038.0-038.9 Septicemia
276.2 Acidosis
276.4 Metabolic acidosis/alkalosis
286.6 Defibrination syndrome/disseminated intravascular coagulation
288.00-288.09 Agranulocytosis/neutropenia
288.8 Other specified disease of white blood cells including leukemoid
reaction/leukocytosis306.53 Psychogenic dysuria
306.59 Other psychogenic genitourinary malfunction518.82 Other pulmonary insufficiency, not elsewhere classified570 Acute and subacute necrosis of liver580.0-580.9 Acute glomerulonephritis583.0-583.9 Nephritis and Nephropathy, not specified as acute or chronic585.6 End stage renal disease590.00-590.9 Infections of kidney/pyelonephritis acute and chronic592.0-592.9 Calculus of kidney and ureter593.0-593.9 Other disorders of kidney and ureter (cyst, stricture, obstruction, reflux, etc.)
594.0-594.9 Calculus of lower urinary tract595.0-595.9 Cystitis597.0 Urethritis, not sexually transmitted and urethral syndrome597.80-597.89 Other urethritis598.00-598.01 Urethral stricture due to infection 599.0 Urinary tract infection, site not specified599.70 Hematuria599.71 Gross hematuria599.72 Microscopic hematuria600.00-600.91 Hyperplasia of prostate601.0-601.9 Inflammatory diseases of prostate 602.0-602.9 Other disorders of prostate (calculus, congestion, atrophy, etc.)604.0-604.99 Orchitis and epididymitis608.0-608.9 Other disorders of male genital organs (seminal vesiculitis, spermatocele,
etc.)614.0-614.9 Inflammatory disease of ovary, fallopian tube, pelvic cellular tissue, and
peritoneum615.0-615.9 Inflammatory disease of uterus, except cervix616.0 Cervicitis and endocervicitis616.10-616.11 Vaginitis and vulvovaginitis616.2-616.9 Other inflammatory conditions of cervix, vagina and vulva619.0-619.9 Fistual involving female genital tract625.6 Stress incontinence, female
URINE CULTURE
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URINE CULTURE
639.0 Genital tract and pelvic infection complicating abortion, ectopic or molar
pregnancies639.5 Shock complicating abortion, ectopic or molar pregnancies646.60-646.64 Infections of genitourinary tract in pregnancy670.00-670.04 Major puerperal infection
670.10-670.14 Puerperal endometritis670.20-670.24 Puerperal sepsis670.30-670.34 Puerperal septic thrombophlebitis670.80-670.84 Other major puerperal infection672.00-672.04 Pyrexia of unknown origin during the puerperium724.5 Backache, unspecified771.81-771.83 Septicemia (Sepsis) of newborn780.02 General symptoms, transient alteration of awareness780.60-780.65 Fever and other physiologic disturbances of temperature regulation780.66 Febrile nonhemolytic transfusion reaction780.79 Other malaise and fatigue780.93 Memory loss780.94 Early satiety780.96 Generalized pain780.97 Altered mental status780.99 Other general symptoms785.0 Tachycardia, unspecified785.50-785.59 Shock without mention of trauma788.0-788.99 Symptoms involving urinary system (renal colic, dysuria, retention of urine,
incontinence of urine, frequency, polyuria, nocturia, oliguria, anuria, other
abnormality of urination, urethral discharge, extravasation of urine, other
symptoms of urinary system)789.00-789.09 Abdominal pain789.60-789.69 Abdominal tenderness789.7 Colic
790.7 Bacteremia791.0-791.9 Nonspecific findings on examination of urine (proteinuria, chyluria,
hemoglobinuria, myoglobinuria, biliuria, glycosuria, acetonuria, other cells
and casts in urine, other nonspecific findings on examination of urine)799.3 Debility, unspecified (only for declining functional status)939.0 Foreign body in genitourinary tract, bladder and urethra939.3 Foreign body in genitourinary tract, penisV44.50-V44.6 Artificial cystostomy or other artificial opening of urinary tract statusV55.5-V55.6 Attention to cystostomy or other artificial opening of urinary tractV58.69 Long-term (current) use of other medications
Reviewed: April 2013
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CPT: 82306 Vitamin D; 25 Hydroxy, includes fraction(s), if performed
CPT: 82652 Vitamin D; 1, 25 Hydroxy, includes fraction(s), if performed
252.00 Hyperparathyroidism, unspecified
252.01 Primary hyperparathyroidism
252.02 Secondary hyperparathyroidism, non-renal
252.08 Other hyperparathyroidism
252.1 Hypoparathyroidism
261 Nutritional marasmus
262 Other severe protein-calorie malnutrition
268.0 Rickets active268.2 Osteomalacia unspecified268.9* Unspecified vitamin D deficiency275.3 Disorders of phosphorus metabolism275.40* Unspecified disorder of calcium metabolism275.41 Hypocalcemia275.42 Hypercalcemia278.4 Hypervitaminosis D571.9 Unspecified chronic liver disease without alcohol
579.0 Celiac disease579.1 Tropical sprue579.2 Blind loop syndrome579.3 Other and unspecified postsurgical nonabsorption579.4 Pancreatic steatorrhea579.8 Other specified intestinal malabsorption579.9 Unspecified intestinal malabsorption585.3 Chronic kidney disease, Stage III (moderate)585.4 Chronic kidney disease, Stage IV (severe)585.5 Chronic kidney disease, Stage V585.6 End Stage Renal Disease588.81 Secondary hyperparathyroidism, (of renal origin)733.00 Osteoporosis unspecified733.01 Senile osteoporosis733.02 Idiopathic osteoporosis733.09 Other osteoporosis733.90 Disorder of bone and cartilage unspecified756.52 Osteopetrosis
268.9* If more than one LCD-listed condition contributes to Vit. D deficiency in a
given patient and/or is improved by Vit. D administration, coders should use:
ICD-9-CM 268.9 UNSPECIFIED VITAMIN D DEFICIENCY. This code should not
be used for any other indication.275.40* Use only for HYPERCALCINURIA
268.0 Rickets active268.2* Osteomalacia unspecified275.40* Unspecified disorder of calcium metabolism275.42* Hypercalcemia
VITAMIN D ASSAY TESTING
The following ICD-9 CM codes support the medical necessity of CPT code 82306
The following ICD-9-CM codes support the medical necessity of CPT code 82652
126 Vitamin D Assay Testing (LCD)
Medicare A Medical Policy February 8, 2011
VITAMIN D ASSAY TESTING
592.0 Calculus of kidney592.1 Calculus of ureter592.9 Urinary calculus unspecified
268.2* Use only for tumor-induced osteomalacia275.40* Use only for unexplained hypercalcinuria275.42* Use only for unexplained hypocalcemia
Reviewed: April 2013
127 Vitamin D Assay Testing (LCD)
Common ICD-9 Codes
AFP - Alpha Fetoprotein DIGOXIN
571.5 Cirrhosis of the liver, unspecified 427.31 Atrial fibrillation
070.32 Hepatitis B, Chronic 429.2 Cardiovascular disease, unspecified
070.54 Hepatitis C, Chronic 428.0 Congestive Heart Failure (CHF)
795.89 Other abnormal tumor markers 244.9 Hypothyroidism, unspecified
571.49 Other chronic hepatitis V58.69 Long term (current) use of other meds
BNP - B-type Natriuretic Peptide 780.79 Malaise and fatigue
519.11 Acute bronchospasm 586 Renal Failure, unspecified
493.92 Asthma unspecified with (acute) 276.7 Hyperkalemia (Hyperpotassemia)
493.22 Chronic obstructive asthma with (acute) 784.0 Headache
428.0 Congestive heart failure, unspec 780.2 Syncope & collapse
428.9 Heart failure unspecified GGT - Gamma Glutamyltransferase
428.1 Left heart failure 571.5 Cirrhosis of the liver, unspecified
425.4 Orther primary cardiomyopathies 250.00 Diabetes mellitus
786.09 Respiratory abnormality other 562.11 Diverticulitis of colon
786.05 Shortness of breath 070.30 Hepatitis B, unspecified
786.07 Wheezing 789.1 Hepatomegaly
CA125 042 HIV disease
V10.43 Hx malignant neoplasm, ovary 272.4 Hyperlipidemia
183.0 Malignant neoplasm of the ovary 782.4 Jaundice, unspecified, not of newborn
795.89 Other abnormal tumor markers V58.61 Long term (current) use of anticoags
789.39 Pelvic swelling, mass or lump V58.69 Long term (current) use of other meds
CA15-3/CA27.29 780.79 Malaise and fatigue
174.9 CA of female breast, unspecified 790.5 Nonspecific abn'l serum enzyme levels
V10.3 Hx of malignant neoplasm, breast 790.4 Nonspecific elevation of transaminase or
795.89 Other abnormal tumor markers 586 Renal Failure, unspecified
198.81 Secondary malignant neoplasm, breast 079.99 Unspecified viral infection
CA19-9 GLUCOSE
V10.09 Hx of malig neoplasm to other GI sites 783.21 Abnormal loss of weight
156.0 Malignant neoplasm , gallbladder 783.1 Abnormal weight gain
795.89 Other abnormal tumor markers 786.50 Chest pain, unspecified
157.9 Pancreatic CA, part unspecified 414.00 Coronary Artery Disease (CAD)
COMPLETE BLOOD COUNT 250.00 Diabetes mellitus
789.00 Abdominal pain, site unspecified 780.4 Dizziness and giddiness
783.21 Abnormal loss of weight 790.29 Hyperglycemia
280.9 Anemia, Iron Deficiency 272.4 Hyperlipidemia
285.9 Anemia, unspecified 251.2 Hypoglycemia
281.9 Anemia, unspecified deficiency V58.69 Long term (current) use of other meds
136.9 Infection, unspecified 780.79 Malaise and fatigue
V58.61 Long term (current) use of anticoags 263.9 Malnutrition, unspecified
V58.69 Long term (current) use of other meds 729.1 Myalgia & Fibromyalgia
041.12 MRSA 791.0 Proteinuria
CARCINOEMBRYONIC ANTIGEN (CEA) 780.39 Seizures, not otherwise specified
V67.2 Follow-up post chemotherapy GLYCOLATED HEMOGLOBIN (HGB A1C)
V10.05 Hx of malignant neoplasm of colon 250.00 Diabetes Mellitis
153.9 Malignant neoplasm of colon 790.29 Hyperglycemia
183.0 Malignant neoplasm of ovary 251.2 Hypoglycemia unspecified
150.9 Malignant neoplasm of the esophagus V58.69 Long term (current) use of other meds
790.99 Nonspecific findings on exam of blood 275.09 Other disorders of iron metabolism
795.89 Other abnormal tumor markers 577.1 Pancreatitis, chronic
579.3 Unspecified surgical nonabsorption
This list comprises only the most commonly used ICD-9 codes and is not intended to be all-inclusive. It is provided as
an "at-a glance" tool to supplement the LCD & NCD Policies. ICD-9 codes must always be substantiated by patients'
medical records.
128 April 2013
Common ICD-9 Codes
HCG-QUANT IRON & FERRITIN; continued�
V10.43 Hx malignant neoplasm, ovary 533.90 Peptic ulcer, unspecifiec
V10.47 Hx malignant neoplasm, testis 570 Necrosis of the liver
186.9 Malig neoplasm of other, unspec testis 704.00 Hair loss
183.0 Malignant neoplasm of the ovary V08 Asymptomatic HIV infection status
632 Missed abortion V12.3 Hx of anemia
338.3 Neoplasm related pain V12.1 Hx of nutirtional deficiency
795.89 Other abnormal tumor markers 790.4 Elevated transaminase or LDH
625.9 Pelvic pain, female LIPID AND CHOLESTEROL
640.00 Threatened abortion 585.9 Chronic renal failure, unspecified
HEPATITIS PANEL, ACUTE 428.0 Congestive Heart failure (CHF)
789.00 Abdominal pain, unspecified 414.00 Coronary atherosclerosis (CAD)
794.8 Abnormal liver scan 250.00 Diabetes mellitus, unspecified
783.1 Abnormal weight gain 272.4 Hyperlipidemia, unspecified
783.21 Abnormal weight loss 401.9 Hypertension, essential, unspecified
783.0 Anorexia 244.9 Hypothyroidism
571.5 Cirrhosis of liver,unspecified V58.69 Long term (current) use of other meds
790.4 Elevated transaminase or LDH 263.9 Malnutrition, unspecified
573.3 Hepatitis, unspecified 278.00 Obesity
789.1 Hepatomegaly V81.2 Screening for unspec cardiovascular
782.4 Jaundice, not of newbown
V72.85 Liver transplant recipient evaluation MAGNESIUM
789.61 Localized tenderness (RUQ) 783.21 Abnormal loss of weight
787.01 Nausea and vomiting 410.90 Acute MI,unspecified site
780.79 Other malaise and fatigue 427.31 Atrial fibrillation
070.9 Viral hepatitis, unspecified 585.9 Chronic renal failure, unspecified
HIV 780.39 Convulsions
783.21 Abnormal loss of weight 252.00 Hyperparathyroidism
786.4 Abnormal sputum V58.69 Long term (current) use of meds
285.9 Anemia, unspecified V58.65 Long-term (current) use of steroids
112.9 Candidiasis, site unspecified 780.79 Malaise and fatigue
682.9 Cellulitis, unspecified site 263.9 Malnutrition, unspecified
786.2 Cough 790.6 Other abnormal blood chemistry
294.8 Dementia 415.19 Pulmonary embolism
787.91 Diarrhea 780.2 Syncope and collapse
780.60 Fever, unspecified 785.0 Tachycardia, unspecified
780.79 Malaise and fatigue NTX - Collagen Cross Links
263.9 Malnutrition, unspecified 242.90 Hyperthyroidism
486 Pneumonia, unspecified V58.69 Long term(current)use of other meds
070.9 Viral hepatitis, unspecified 733.00 Osteoporosis
HIV Viral Load 621.7 Postmenopausal bleeding
042 HIV disease 256.9 Unspecified ovarian dysfunction
V08 Asymptomatic HIV infection status OCCULT BLOOD; FECES SCREENING
079.53 HIV Type 2 789.00 Abdominal pain, site unspecified
IRON & FERRITIN; continued in next column 783.21 Abnormal loss of weight
280.9 Anemia, iron deficient, unspecified 280.9 Anemia, Iron Deficiency
285.9 Anemia, unspecified 285.9 Anemia, unspecified
281.9 Anemia, unspecified deficiency 787.91 Diarrhea
427.31 Atrial fibrillation 578.9 GI bleed
428.0 Congestive Heart Failure (CHF) V58.61 Long term (current) use of anticoags
250.00 Diabetes mellitus, unspecified V58.69 Long term (current) use of other meds
263.9 Malnutrition, unspecified
790.6 Other abnormal blood chemistry
586 Renal failure, unspecified
070.9 Viral hepatitis, unspecified
129 April 2013
Common ICD-9 Codes PROSTATE SPECIFIC ANTIGEN (PSA) THYROID TESTING; continued�
600.00 BPH, Benign prostate hypertrophy 250.00 Diabetes mellitus, unspecified
790.93 Elevated prostate specific antigen 780.60 Fever
599.70 Hematuria 240.9 Goiter, unspecified
185 Malignant neoplasm of prostate 272.4 Hyperlipidemia, unspecified
788.43 Nocturia 401.9 Hypertension Essential unspecified
V10.46 Personal history of prostate cancer 242.90 Hyperthyroidism, unspecified
788.20 Retention of urine, unspecified 244.9 Hypothyroidism, unspecified
V76.44 Screening Code - freq limitation V58.69 Long term (current) use of other meds
602.9 Unspecified disorder of prostate 780.79 Malaise and fatigue
601.9 Unspecified prostatitis 780.93 Memory Loss
788.63 Urgency of urination 782.0 Numbness
788.41 Urinary frequency 785.1 Palpitations
788.30 Urinary incontinence, unspecified 290.0 Senile dementia, uncomplicated
599.60 Urinary obstruction, unspecified URINALYSIS (UA)
PROTHROMBIN TIME (PT) 789.00 Abdominal pain, unspecified
790.92 Abnormal coagulation profile 428.0 Congestive heart failure
427.31 Atrial fibrillation 250.00 Diabetes mellitus, unspecified
434.91 Cerebrovascular accident (CVA) 788.1 Dysuria
585.9 Chronic renal failure, unspecified 780.60 Fever, unspecified
V12.50 Circulatory Disease, unspecified 599.70 Hematuria
286.9 Coagulation defect, unspecified 401.9 Hypertension, Essential, unspecified
428.0 Congestive heart failure (CHF) V58.69 Long term (current) use of other meds
414.00 Coronary atherosclerosis (CAD) 780.79 Malaise and fatigue
562.11 Diverticulitis of colon, w/o hemorrhage 780.97 Mental status changes
782.3 Edema 788.43 Nocturia
599.70 Hematuria 791.9 Nonspecific findings on exam of urine
V58.61 Long term (current) use of anticoags 593.9 Renal Insufficiency
443.9 Peripheral vascular disease, unspec 788.20 Retention of urine, unspecified
586 Renal failure, unspecified 714.0 Rheumatoid arthritis
786.05 Shortness of breath 788.41 Urinary frequency
780.2 Syncope and collapse 788.30 Urinary incontinence, unspecified
453.9 Thrombosis of unspecified site 599.0 Urinary tract infection (UTI)
281.9 Unspecified Deficiency Anemia URINE CULTURE
PARTIAL THROMBOPLASTIN TIME (PTT) 789.00 Abdominal pain, unspecified
427.31 Atrial fibrillation 724.5 Backache, unspecified
786.50 Chest pain, unspecified 790.7 Bacteremia
585.9 Chronic renal failure, unspecified 585.9 Chronic renal failure, unspecified
571.5 Cirrhosis of the liver, unspecified 780.60 Fever
286.9 Coagulation defects, unspecified 599.70 Hematuria
428.0 Congestive heart failure (CHF) V58.69 Long term (current) use of other meds
820.8 Fracture, hip 780.93 Memory loss
599.70 Hematuria 780.97 Mental status changes
V58.61 Long term (current) use of anticoags 791.9 Nonspecific findings on exam of urine
786.05 Shortness of breath 780.79 Other malaise and fatigue
780.2 Syncope 038.9 Septicemia, unspecified
THYROID TESTING; continued in next column 599.0 Urinary tract infection
783.21 Abnormal loss of weight VITAMIN D
783.1 Abnormal weight gain 579.0 Celiac disease
331.0 Alzheimer's disease Chronic kidney disease (Stage III through
285.9 Anemia, unspecified
300.00 Anxiety, unspecified 275.42 Hypercalcemia
427.31 Atrial fibrillation 252.00 Hyperparathyroidism, unspecified
428.0 Congestive heart failure (CHF) 733.00 Osteoporosis unspecified
564.00 Constipation, unspecified 571.9 Unspecified chronic liver disease
294.8 Dementia 268.9 Unspecified vitamin D deficiency
311 Depression
585.3 -
585.6
130 April 2013
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