Medicare National and Local Coverage Determination Policy – FLORIDA

Transcription

Medicare National and Local Coverage Determination Policy – FLORIDA
Policies in this MLCP Reference Guide apply to testing performed at a Quest Diagnostics facility and apply to Medicare National Coverage Determination Policy.
This diagnosis code reference guide is provided as an aid to physicians and office staff in determining when an ABN (Advance Beneficiary Notice) is necessary.
Diagnosis codes must be applicable to the patient’s symptoms or conditions and must be consistent with documentation in the patient’s medical record.
Quest Diagnostics does not recommend any diagnosis codes and will only submit diagnosis information provided to us by the ordering physician or his/her
designated staff. The CPT codes provided are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the
billing party. Please direct any questions regarding coding to the payer being billed.
Please note this document has been updated with National Medicare changes effective 4/1/2012
• Click here for National MLCP Policies Tool
Document contains information on National Medicare
Limited Coverage Policies
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Alpha-Fetoprotein
Blood Counts
Blood Glucose Testing
Carcinoembryonic Antigen
Collagen Crosslinks - Any Method
Digoxin Therapeutic Drug Assay
Fecal Occult Blood
Gamma Glutamyl Transferase
Glycated Hemoglobin - Glycated Protein
Hepatitis Panel/Acute Hepatitis Panel
Human Chorionic Gonadotropin
Human Immunodeficiency Virus (HIV) Testing
(Diagnosis)
Human Immunodeficiency Virus (HIV) Testing
(Prognosis Including Monitoring)
Lipids Testing
Partial Thromboplastin Time (PTT)
Prostate Specific Antigen
Prothrombin Time (PT)
Serum Iron Studies
Thyroid Testing
Tumor Antigen by Immunoassay CA 15-3 CA 27.29
Tumor Antigen by Immunoassay CA 19-9
Tumor Antigen by Immunoassay CA-125
Urine Culture, Bacterial
• Click policy below for Local MLCP Policy Tool
Document contains the below Medicare Local MLCP
Coverage Policies for lab testing performed in Florida
Allergy Testing
Aluminum
B-Type Natriuretic Peptide (BNP)
Circulating tumor cell testing
Flow Cytometry
Hepatitis B Surface Antibody
Hepatitis B Surface Antigen
Ionized Calcium
Magnesium
Non-Covered ICD 9
Parathormone, (Parathyroid Hormone)
Qualitative Drug Screening
Sedimentation Rate
Serum Phosphorus
Susceptibility Studies
Syphilis
Total, Calcium
Vitamin D:25 Hydroxy, includes Fraction(S) if performed
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Last Updated:
12/05/2013
Medicare Local Coverage Determination Policy – Florida
Allergy Testing (L31271) 1 OF 2
Data Source: http://www.cms.gov
CPT Code 86003
LCD Description: Allergy is a form of exaggerated sensitivity or hypersensitivity to a substance that is either inhaled, ingested, injected, or comes in contact with
the skin or eye. The term allergy is used to describe situations where hypersensitivity results from heightened or altered reactivity of the immune system in response
to external substances. Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions as well as localized reactions in any part of the
body. The reactions may be acute, sub-acute, or chronic, immediate or delayed, and may be caused by a variety of offending agents; pollen, molds, mites, dust,
feathers, animal fur or dander, venoms, foods, drugs, etc.
Allergy testing is performed to determine a patient's immunologic sensitivity or reaction to particular allergens for the purpose of identifying the cause of the allergic
state, and is based on findings during a complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient.
ICD-9-CM Codes that Support Medical Necessity: The Allergy Testing test is determined to be medically necessary by Medicare only when it is ordered for
patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct
payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that
diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National
Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference.
372.05
372.14
477.0
477.1
477.2
477.8
477.9
493.00
493.01
493.02
493.90
493.91
493.92
691.8
692.9
693.0
ACUTE ATOPIC CONJUNCTIVITIS
OTHER CHRONIC ALLERGIC CONJUNCTIVITIS
ALLERGIC RHINITIS DUE TO POLLEN
ALLERGIC RHINITIS DUE TO FOOD
ALLERGIC RHINITIS, DUE TO ANIMAL (CAT) (DOG)
HAIR AND DANDER
ALLERGIC RHINITIS DUE TO OTHER ALLERGEN
ALLERGIC RHINITIS CAUSE UNSPECIFIED
EXTRINSIC ASTHMA UNSPECIFIED
EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS
EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION
ASTHMA UNSPECIFIED
ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS
ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION
OTHER ATOPIC DERMATITIS AND RELATED CONDITIONS
CONTACT DERMATITIS AND OTHER ECZEMA,
UNSPECIFIED CAUSE
DERMATITIS DUE TO DRUGS AND MEDICINES TAKEN
INTERNALLY
693.1
693.8
693.9
708.0
708.3
708.8
708.9
782.1
989.5
989.82
995.0
995.1
995.20
995.22
DERMATITIS DUE TO FOOD TAKEN INTERNALLY
DERMATITIS DUE TO OTHER SPECIFIED SUBSTANCES
TAKEN INTERNALLY
DERMATITIS DUE TO UNSPECIFIED SUBSTANCES TAKEN
INTERNALLY
ALLERGIC URTICARIA
DEMATOLOGRAPHIC URTICARIA
OTHER SPECIFIED URTICARIA
UNSPECIFIED URTICARIA
RASH OR OTHER NONSPECIFIED SKIN ERUPTION
TOXIC EFFECT ON VENOM
TOXIC EFFECT OF LATEX
OTHER ANAPHYLACTIC REACTION
ANGIONEUROTIC EDEMA NOT ELSEWHERE CLASSIFIED
UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG
MEDICINAL AND BIOLOGICAL SUBSTANCE
UNSPECIFIED ADVERSE EFFECT OF ANESTHESIA
* ICD-9-CM code V15.09 should be used as a secondary code only and should not be billed as the primary diagnosis.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
12/5/13
Allergy Testing (L31271) 2 OF 2
CPT Code 86003
LCD Description: Allergy is a form of exaggerated sensitivity or hypersensitivity to a substance that is either inhaled, ingested, injected, or comes in contact with
the skin or eye. The term allergy is used to describe situations where hypersensitivity results from heightened or altered reactivity of the immune system in response
to external substances. Allergic or hypersensitivity disorders may be manifested by generalized systemic reactions as well as localized reactions in any part of the
body. The reactions may be acute, sub-acute, or chronic, immediate or delayed, and may be caused by a variety of offending agents; pollen, molds, mites, dust,
feathers, animal fur or dander, venoms, foods, drugs, etc.
Allergy testing is performed to determine a patient's immunologic sensitivity or reaction to particular allergens for the purpose of identifying the cause of the allergic
state, and is based on findings during a complete medical and immunologic history and appropriate physical exam obtained by face-to-face contact with the patient.
ICD-9-CM Codes that Support Medical Necessity: The Allergy Testing test is determined to be medically necessary by Medicare only when it is ordered for
patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct
payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that
diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list was compiled from the Medicare National
Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference.
995.27
995.29
995.3
995.60 – 995.68
V15.09*
OTHER DRUG ALLERGY
UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE
ALLERY UNSPECIFIED NOT ELSEWHERE CLASSIFIED
ANAPHYLACTIC REACTION
PERSONAL HISTORY OF OTHER ALLERGY OTHER THAN TO MEDICINAL AGENTS
* ICD-9-CM code V15.09 should be used as a secondary code only and should not be billed as the primary diagnosis.
Last Updated:
12/5/13
Medicare Local Coverage Determination Policy - Florida
Aluminum (L29058)
CPT Code 82108
LCD Description: Aluminum is the third most prevalent element in the earth’s crust. The gastrointestinal tract is virtually impervious to aluminum,
absorption being around 2%. Factors regulating aluminum’s crossing of the blood-brain barrier are not well understood. Serum aluminum correlates
with encephalopathy. Aluminum toxicity has been recognized in many settings where exposure is heavy or prolonged and/or where renal function is
limited.
ICD-9-CM Codes that Support Medical Necessity: The Aluminum test is determined to be medically necessary by Medicare only when it is
ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the
procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be
reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the
test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete
reference.
268.2
275.49
280.9
284.81 – 284.89
284.9
285.1
294.8
348.30 – 348.39
359.4*
428.1
429.3
585.1 – 585.9
733.10 – 733.19
965.1
972.2
973.0
976.1
OSTEOMALACIA UNSPECIFIED
OTHER DISORDERS OR CALCIUM METABOLISM
IRON DEFICIENCY ANEMIA UNSPECIFIED
RED CELL APLASIA(ACQUIRED) (ADULT) (WITH
THYMOMA) – OTHER SPECIFIED APLASTIC ANEMIAS
APLASTIC ANEMIA UNSPECIFIED
ACUTE POSTHEMORRHAGIC ANEMIA
OTHER PERSISTENT MENTAL DISORDERS DUE TO
CONDITIONS CLASSIFIED ELSEWHERE
ENCEPHAOPATHY UNSPECIFIED – OTHER
TOXIC MYOPATHY
LEFT HEART FAILURE
CARDIOMEGALY
CHRONIC KIDNEY DISEASE, STAGE 1 – CHRONIC
KIDNEY DISEASE UNSPECIFIED
PATHOLOGICAL FRACTURE UNSPECIFIED/OTHER SITE
POISONING BY SALICYLATES
POISONING BY ANTILIPEMIC AND
ANTIARTERIOSCLEROTIC DRUGS
POISONING BY ANTACIDS AND ANTIGASTRIC SECRETION
DRUGS
POISIONING BY ANTIPRURITICS
976.2
POISONING BY LOCAL ASTRINGENTS AND LOCAL
DETERGENTS
976.3
POISONING BY EMOLLIENTS DEMULCENTS AND
PROTECTANTS
985.9
TOXIC EFFECT OR UNSPECIFIED METAL
E858.3*
ACCIDENTAL POISONING BY AGENTS PRIMARILY
AFFECTING CARDIOVASCULAR SYSTEM
E858.4*
AFFECTING GASTOINTESTINAL SYSTEM
E858.7*
AFFECTING SKIN AND MUCOUS MEMBRANE
OPTHALMOLOGICAL OTORHINOLARYNGOLOGICAL AND
DENTAL DRUGS
E935.3*
SALICYLATES CAUSING ADVERSE EFFECTS IN
THERAPEUTIC USE
E942.2*
ANTILIPEMIC AND ANTIARTERIOSCLEROTIC DRUGS
CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
E943.0*
ANTACIDS AND ANTIGASTRIC SECRETION DRUGS CAUSING
ADVERSE EFFECTS IN THERAPEUTIC USE
E946.2* - E946.3* ASTRINGENTS/EMOLLIENTS CAUSING ADVERSE EFFECTS
E950.0*
SUICIDE AND SELF-INFLICTED POISONING
E950.4*
SUICIDE AND SELF-INFLICTED POISONING - OTHER
* These ICD-9-CM codes require dual diagnosis. ICD-9-CM code 359.4 must be accompanied by the appropriate E diagnosis code to identify the
toxic agent. Conversely, the E diagnosis codes must be billed with ICD-9-CM code 359.4 to identify the indication of toxic myopathy.
Last Updated:
12/5/13
B-Type Natriuretic Peptide (BNP) (L29065)
CPT Code 83880
LCD Description:. LCD Description:. Congestive Heart Failure (CHF) is characterized by a progressive activation of the neurohormonal systems that
control vasoconstriction and sodium retention; the activation of these systems plays a role in its pathogenesis and progression. As the heart fails, B-Type
Natriuretic Peptide (BNP), a cardiac neurohormone is secreted from the cardiac ventricles in response to ventricular volume expansion and pressure
overload. Used in conjunction with other clinical information, rapid measurement of BNP is useful in establishing or excluding the diagnosis and
assessment of severity of CHF in patients with acute dyspnea so that appropriate and timely treatment can be initiated. This test is also used to predict
the long-term risk of cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after an acute
coronary event. For the purposes of this policy, the total and N terminal assays are both acceptable.
ICD-9-CM Codes that Support Medical Necessity: The B-Type Natriuretic Peptide (BNP is determined to be medically necessary by Medicare only when it
is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the
procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable
and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided
402.01
402.11
402.91
404.01
MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE
BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE
UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE
AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED
404.03
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE
AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
404.11
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND
WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED
404.13
CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
404.91
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE
AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED
404.93
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE
AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
410.00 - 410.92
ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE
UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT
EPISODE OF CARE
411.1
INTERMEDIATE CORONARY SYNDROME
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
428.30
428.31
428.32
428.33
428.40
428.41
428.42
428.43
428.9
786.00
786.02
786.05
786.06
786.07
786.09
ACUTE ON CHRONIC SYSTOLIC
HEART FAILURE
UNSPECIFIED DIASTOLIC HEART
FAILURE
ACUTE DIASTOLIC HEART FAILURE
CHRONIC DIASTOLIC HEART FAILURE
ACUTE ON CHRONIC DIASTOLIC HEART
FAILURE
UNSPECIFIED COMBINED SYSTOLIC
AND DIASTOLIC HEART FAILURE
ACUTE COMBINED SYSTOLIC
CHRONIC COMBINED SYSTOLIC
ACUTE ON CHRONIC COMBINED
SYSTOLIC AND DIASTOLIC HEART FAILURE
HEART FAILURE UNSPECIFIED
RESPIRATORY ABNORMALITY UNSPECIFIED
ORTHOPNEA
SHORTNESS OF BREATH
TACHYPNEA
WHEEZING
RESPIRATORY ABNORMALITY OTHER
Last Updated:
12/5/13
Circulating tumor cell testing (L32098)
CPT Codes 86152 and 86153
LCD Description: Circulating tumor cells (CTCs) are rare malignant cells found in the peripheral blood which originate from the primary tumor or
metastatic sites. The
Detection of CTCs has several propased application, some of which have been reported in well-designed observational studies (prospective and
retrospective) of patients with metastatic cancers. There are also several controlled clinical trials in progress assessing the clinical utility of CTC
results in the care of patients with metastatic cancers (appliction in clinical decision making that impacts patient outcomes). There are several
methods of detecting CTCs whick are in various stages of reseaarch and development. The low level of concentration of malignant epithelial cells in
blood samples makes them diffcult to detect though the push to improve surveilance and treatment of cancer patients makes CTC an area of
research development. The techniques that have been used to detect CTCs include direct methods (enrichment/detection) including
Immunomagnetic Bead Separation, Immunohistochemistry (IHC), automated fluorescent methods. Dielectrophoresis and indirect methods (reversetranscriptase polymerase chain reaction (RT-PCR) nucleic acid analysis).
ICD-9-CM Codes that Support Medical Necessity: The Circulating tumor cell testing is determined to be medically necessary by Medicare only
when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not
enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the
procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the
medical necessity for the test(s) provided
153.0 - 153.9
154.0 - 154.8
174.0 - 174.9
175.0 - 175.9
185
196.0
198.3
198.5
MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE
MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION - MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM
RECTOSIGMOID JUNCTION AND ANUS
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST
(FEMALE) UNSPECIFIED SITE
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST - MALIGNANT NEOPLASM OF OTHER AND
UNSPECIFIED SITES OF MALE BREAST
MALIGNANT NEOPLASM OF PROSTATE
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK
SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD
SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
Last Updated:
12/5/13
Flow Cytometry (L31247) 1 of 4
CPT Codes 88182, 88184, 88185, 88187, 88188 and 88189
LCD Description: Flow cytometry (FCM) is a procedure which simultaneously measures and analyzes multiple physical characteristics of single cells, as they flow in a fluid stream through a
beam of light. The light activates fluorescent molecules, resulting in light scatter, which forms a pattern that can be analyzed for cell characteristics. FCM can be used to analyze blood, body
fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid organs. Information from the analyzed cells may help determine prognosis, aid in the analysis of effusions, urine, or other
fluids in which cancer cells may be few or mixed with benign cells, detect metastases in lymph nodes or bone marrow, or to supplement fine needle aspiration. The flow cytometer is made up
of three main systems: fluidics, optics and electronics. The fluidic system transports particles in a stream to the laser beam. The optics system consists of lasers to illuminate the particles in the
sample stream and optical filters to direct the resulting light signals to the appropriate detectors. The electronics system converts the detected light signals into electronic signals that can be
processed by the computer. Some flow cytometers have a sorting feature which allows the electronic system to initiate sorting decisions to charge and deflect particles.
ICD-9-CM Codes that Support Medical Necessity: The Flow Cytometry test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the
conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the
medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference.
CPT 88182
151.0 - 151.9
153.0 - 153.9
154.1
164.2
164.3
174.0 - 174.9
175.0 - 175.9
182.0
183.0
183.8
185
188.0 - 188.8
189.0
189.1
191.0 - 191.9
630
MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE
MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE
MALIGNANT NEOPLASM OF RECTUM
MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM
MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST - MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST
MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS
MALIGNANT NEOPLASM OF OVARY
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA
MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER - MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER
MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS
MALIGNANT NEOPLASM OF RENAL PELVIS
MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE
HYDATIDIFORM MOLE
USE FOR BILLING CPT CODES 88184, 88185, 88187, 88188, AND 88189
042
079.51
079.52
079.53
099.3
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE I [HTLV-I]
HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE II [HTLV-II]
HUMAN IMMUNODEFICIENCY VIRUS TYPE 2 [HIV-2]
REITER'S DISEASE
* According to the IC9-9-CM book, diagnosis codes V42.0 – V42.9 and 289.83 are secondary codes and should not be billed as a primary diagnosis.
Last Updated:
12/5/13
CPT Codes 88182, 88184, 88185, 88187, 88188 and 88189
150.0 - 150.9 MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS
MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE
151.0 - 151.9 MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM
OF STOMACH UNSPECIFIED SITE
153.0 - 153.9 MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT
NEOPLASM OF COLON UNSPECIFIED SITE
154.0
MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION
154.1
MALIGNANT NEOPLASM OF RECTUM
174.0 - 174.9 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE
BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE)
UNSPECIFIED SITE
175.0 - 175.9 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE
BREAST - MALIGNANT NEOPLASM OF OTHER AND
UNSPECIFIED SITES OF MALE BREAST
183.0
MALIGNANT NEOPLASM OF OVARY
183.8
MALIGNANT NEOPLASM OF OTHER SPECIFIED
SITES OF UTERINE ADNEXA
185
188.0 - 188.9 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER
MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED
193
MALIGNANT NEOPLASM OF THYROID GLAND
194.0
197.2
197.6
200.00 - 208.92
227.0
233.0
238.71 - 238.79
259.2
273.1
273.2
273.3
273.8
273.9
279.00 - 279.9
282.0
282.1
285.9
MALIGNANT NEOPLASM OF ADRENAL GLAND
SECONDARY MALIGNANT NEOPLASM OF PLEURA
SECONDARY MALIGNANT NEOPLASM OF
RETROPERITONEUM AND PERITONEUM
RETICULOSARCOMA UNSPECIFIED SITE
UNSPECIFIED LEUKEMIA, IN RELAPSE
BENIGN NEOPLASM OF ADRENAL GLAND
CARCINOMA IN SITU OF BREAST
ESSENTIAL THROMBOCYTHEMIA – OTHER
LYMPHATIC AND HEMATOPOIETIC TISSUES
CARCINOID SYNDROME
MONOCLONAL PARAPROTEINEMIA
OTHER PARAPROTEINEMIAS
MACROGLOBULINEMIA
OTHER DISORDERS OF PLASMA PROTEIN METABOLISM
UNSPECIFIED DISORDER OF PLASMA PROTEIN METABOLISM
HYPOGAMMAGLOBULINEMIA UNSPECIFIED - UNSPECIFIED
DISORDER OF IMMUNE MECHANISM
HEREDITARY SPHEROCYTOSIS
HEREDITARY ELLIPTOCYTOSIS
ANEMIA UNSPECIFIED
Last Updated:
12/5/13
CPT Codes 88182, 88184, 88185, 88187, 88188 and 88189
287.1
287.30 – 287.39
287.5
288.00 – 288.09
288.1
288.2
288.3
288.4
288.50 – 288.59
288.60
288.61
288.62
288.64
288.65
288.69
288.8
288.9
289.4
289.50 – 289.59
289.83*
QUALITATIVE PLATELET DEFECTS
PRIMARY THROMOCYTOPENIA, UNSPECIFIED – OTHER
THROMBOCYTOPENIA UNSPECIFIED
NEUTROPENIA, UNSPECIFIED – OTHER
FUNCTIONAL DISORDERS OF POLYMORPHONUCLEAR
NEUTROPHILS
GENETIC ANOMALIES OF LEUKOCYTES
EOSINOPHILIA
HEMOPHAGOCYTIC SYNDROMES
LEUKOCYTOPENIA, UNSPECIFIED – OTHER DECREASE
WHITE BLOOD CELL COUNT
LEUKOCYTOSIS, UNSPECIFIED
LYMPHOCYTOSIS (SYMPTOMATIC)
LEUKMOID REACTION
PLASMACYTOSIS
BASOPHILIA
OTHER ELEVATED WHITE BLOOD CELL COUNT
OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS
UNSPECIFIED DISEASE OF WHITE BLOOD CELLS
HYPERSPLENISM
DISEASE OF SPLEEN UNSPECIFIED, OTHER
MYELOFIBROSIS
289.9
364.3
452
453.9
555.0 – 555.9
556.0
556.1
556.2
556.3
556.4
556.5
556.6
556.9
630..
696.0
714.30
720.0 – 720.9
UNSPECIFIED DISEASES OF BLOOD AND BLOOD-FORMING
ORGANS
UNSPECIFIED IRIDOCYCLITIS
PORTAL VEIN THROMBOSIS
EMBOLISM AND THROMBOSIS OF UNSPECIFIED SITE
REGIONAL ENTERITIS OF SMALL INTESTINE – REGIONAL
ENTERITIS OF UNSPECIFIED SITE
ULCERATIVE (CHRONIC) ENTEROCOLITIS
ULCERATIVE (CHRONIC) ILEOCOLOYIS
ULCERATIVE (CHRONIC) PROCTITIS
ULCERATIVE (CHRONIC) PROCTOSIGMOIDITIS
PSEUDOPOLYPOSIS OF COLON
LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS
UNIVERSAL ULCERATIVE (CHRONIC) COLITIS
ULCERATIVE COLITIS UNSPECIFIED
HYDATIDIFORM MOLE
PSORIATIC ARTHROPATHY
CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE
RHEUMATOID ARTHRITIS
ANKYLOSING SPONDYLITIS – UNSPECIFIED INFLAMMATORY
SPONDYLOPATHY
Last Updated:
12/5/13
CPT Codes 88182, 88184, 88185, 88187, 88188 and 88189
785.6
789.2
789.30 – 789.39
791.0
795.4
996.80 – 996.89
V08
V10.60 – V10.69
V42.0 – V42.9
ENLARGEMENT OF LYMPH NODES
SPLENOMEGALY
ABDOMINAL OR PELVIC SWELLING MASS OR LUMP
UNSPECIFIED/OTHER SITE
PROTEINURIA
OTHER NONSPECIFIED ABNORMAL HISTOLOGICAL FINDINGS
COMPLICATIONS OF UNSPECIFIED/OTHER TRANSPLANTED
ORGAN
ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV)
INFECTION
PERSONAL HISTORY OF UNSECIFIED/OTHER LEUKEMIA
KIDNEY REPLACED BY TRANSPLANT – UNSPECIFIED ORGAN
OR TISSUE REPLACED BY TRANSPLANT
Last Updated:
12/5/13
Hepatitis B Surface Antibody (L29189) 1 of 2
CPT Code 86706
LCD Description:. Hepatitis refers to inflammation of the liver. Approximately 50% of all acute viral hepatitis cases in the United States are type B. Hepatitis B is caused by the hepatitis B
virus (HBV) which is spread by blood and serum-derived fluids through direct contact with these body fluids (such as transmission through parenteral, sexual and perinatal modes). The
incubation period for hepatitis B can be six weeks to six months with a slow onset. The most frequent presenting symptoms of acute viral hepatitis are low-grade fever, anorexia, fatigue,
myalgia, and nausea followed one to two weeks later by jaundice. Dark urine and clay colored stools present several days before jaundice. After the onset of jaundice, the liver enlarges
and becomes tender. About 5% of patients infected with the hepatitis B virus develop what is coined the “serum-sickness syndrome”. The syndrome includes the symptoms of jaundice,
fever, rash and arthralgia. Hepatitis B may be quite mild, while a few patients could rapidly progress to death suffering from acute necrosis of the liver. Some patients with hepatitis B
(approximately 6%-10%) may progress to a persistent carrier status confirmed by the consistently present hepatitis B surface antigen in their blood. These patients are highly likely to
transmit hepatitis B. Each case of hepatitis B is treated symptomatically.
Hepatitis B surface antibody (HbsAb or anti-HBs) is present in the serum of patients who have resolved a previous hepatitis B infection or have been vaccinated against hepatitis B. The
disappearance of hepatitis B antigen with the appearance of hepatitis B antibody signals recovery from the hepatitis B infection, the status of noninfectivity and protection from recurrent
hepatitis B infection. Hepatitis B surface antibody can be detected several weeks to several years after Hepatitis B antigen can no longer be detected. It may persist for life after the acute
infection has been resolved. Since there are different serologic subtypes of the hepatitis B virus, it is possible for a patient to have an antibody for one subtype and be infected with
another. Transfused individuals or hemophiliacs receiving plasma components may have false positive tests. Individuals vaccinated with HBV vaccine will have antibodies. The
appearance of the hepatitis B antibody following vaccination signals successful vaccination against hepatitis B. The detection of hepatitis B surface antibody in the patient’s serum can be
performed by either the radioimmunoassay (RIA) or enzyme immunoassay (EIA) method. The reference range varies with the clinical circumstance.
ICD-9-CM Codes that Support Medical Necessity The Hepatitis B Surface Antibody is determined to be medically necessary by Medicare only when it is ordered for patients with one of
the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must
Vaccination and Serologic Studies support the medical necessity for the test(s) provided.
070.20 - 070.23
070.30 - 070.33
403.01
403.11
404.02
404.03
VIRAL HEPATITIS B WITH HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA –
CHRONIC VIRAL HEPATITIS B WITH HEPATIC COMA WITH HEPATITIS DELTA
VIRAL HEPATITIS B WITHOUT HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA –
CHRONIC VIRAL HEPATITIS B WITHOUT HEPATIC COMA WITH HEPATITIS DELTA
HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE
STAGE V OR END STAGE RENAL DISEASE
HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V
OR END STAGE RENAL DISEASE
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND
WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
Freq. of Status HBsAb Surveillance
Unvaccinated
Susceptible - Semiannually
HBsAg Carrier - None
HBsAb positive (*) - Annually
Vaccinated
HBsAb of 9 or less SRUs by RIA – Semiannually
Note: Billing for Hepatitis B Surface Antibody for
ESRD beneficiaries requires dual diagnoses.
Please submit codes 403.01, 403.11, 404.02,
404.03, 404.12, 404.13, or 585.4-585.6 and
*V45.11 to report the approved indication.
* According to the ICD-9-CM book, Diagnosis
code V45.11 is a secondary diagnosis code and
should not be billed as the primary diagnosis.
Last Updated:
12/5/13
Hepatitis B Surface Antibody (L29189) 2 of 2
CPT Code 86706
LCD Description:. Hepatitis refers to inflammation of the liver. Approximately 50% of all acute viral hepatitis cases in the United States are type B. Hepatitis B is caused by the hepatitis B
virus (HBV) which is spread by blood and serum-derived fluids through direct contact with these body fluids (such as transmission through parenteral, sexual and perinatal modes). The
incubation period for hepatitis B can be six weeks to six months with a slow onset. The most frequent presenting symptoms of acute viral hepatitis are low-grade fever, anorexia, fatigue,
myalgia, and nausea followed one to two weeks later by jaundice. Dark urine and clay colored stools present several days before jaundice. After the onset of jaundice, the liver enlarges
and becomes tender. About 5% of patients infected with the hepatitis B virus develop what is coined the “serum-sickness syndrome”. The syndrome includes the symptoms of jaundice,
fever, rash and arthralgia. Hepatitis B may be quite mild, while a few patients could rapidly progress to death suffering from acute necrosis of the liver. Some patients with hepatitis B
(approximately 6%-10%) may progress to a persistent carrier status confirmed by the consistently present hepatitis B surface antigen in their blood. These patients are highly likely to
transmit hepatitis B. Each case of hepatitis B is treated symptomatically.
Hepatitis B surface antibody (HbsAb or anti-HBs) is present in the serum of patients who have resolved a previous hepatitis B infection or have been vaccinated against hepatitis B. The
disappearance of hepatitis B antigen with the appearance of hepatitis B antibody signals recovery from the hepatitis B infection, the status of noninfectivity and protection from recurrent
hepatitis B infection. Hepatitis B surface antibody can be detected several weeks to several years after Hepatitis B antigen can no longer be detected. It may persist for life after the acute
infection has been resolved. Since there are different serologic subtypes of the hepatitis B virus, it is possible for a patient to have an antibody for one subtype and be infected with
another. Transfused individuals or hemophiliacs receiving plasma components may have false positive tests. Individuals vaccinated with HBV vaccine will have antibodies. The
appearance of the hepatitis B antibody following vaccination signals successful vaccination against hepatitis B. The detection of hepatitis B surface antibody in the patient’s serum can be
performed by either the radioimmunoassay (RIA) or enzyme immunoassay (EIA) method. The reference range varies with the clinical circumstance.
ICD-9-CM Codes that Support Medical Necessity The Hepatitis B Surface Antibody is determined to be medically necessary by Medicare only when it is ordered for patients with one of
the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must
Vaccination and Serologic Studies support the medical necessity for the test(s) provided.
404.12
404.13
585.4
585.5
585.6
V01.71 - V01.79
V05.3
V45.11*
V67.59
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE
CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)
CHRONIC KIDNEY DISEASE, STAGE V
END STAGE RENAL DISEASE
CONTACT OR EXPOSURE TO VARICELLA - CONTACT OR EXPOSURE TO OTHER VIRAL DISEASES
NEED FOR PROPHYLACTIC VACCINATION AND INOCULATION AGAINST VIRALHEPATITIS
RENAL DIALYSIS STATUS
OTHER FOLLOW-UP EXAMINATION
Freq. of Status HBsAb Surveillance
Unvaccinated
Susceptible - Semiannually
HBsAg Carrier - None
Vaccinated
HBsAb of 9 or less SRUs by RIA – Semiannually
Note: Billing for Hepatitis B Surface Antibody for
ESRD beneficiaries requires dual diagnoses.
Please submit codes 403.01, 403.11, 404.02,
404.03, 404.12, 404.13, or 585.4-585.6 and
*V45.11 to report the approved indication.
* According to the ICD-9-CM book, Diagnosis
code V45.11 is a secondary diagnosis code and
should not be billed as the primary diagnosis.
Last Updated:
12/5/13
Hepatitis B Surface Antigen (L29189) 1 of 3
CPT Code 87340
LCD Description:. Hepatitis refers to inflammation of the liver. Approximately 50% of all acute viral hepatitis cases in the United States are type B. Hepatitis B is
caused by the hepatitis B virus (HBV) which is spread by blood and serum-derived fluids through direct contact with these body fluids (such as transmission through
parenteral, sexual and perinatal modes). The incubation period for hepatitis B can be six weeks to six months with a slow onset. The most frequent presenting
symptoms of acute viral hepatitis are low-grade fever, anorexia, fatigue, myalgia, and nausea followed one to two weeks later by jaundice. Dark urine and clay colored
stools present several days before jaundice. After the onset of jaundice, the liver enlarges and becomes tender. About 5% of patients infected with the hepatitis B
virus develop what is coined the “serum-sickness syndrome”. The syndrome includes the symptoms of jaundice, fever, rash and arthralgia. Hepatitis B may be quite
mild, while a few patients could rapidly progress to death suffering from acute necrosis of the liver. Some patients with hepatitis B (approximately 6%-10%) may
progress to a persistent carrier status confirmed by the consistently present hepatitis B surface antigen in their blood. These patients are highly likely to transmit
hepatitis B. Each case of hepatitis B is treated symptomatically.
Hepatitis B surface antigen (HBsAg) is the earliest indicator of an acute hepatitis B infection. It can be detected one to seven weeks before liver enzyme elevation or
the onset of clinical symptoms. The serology of 50% of affected patients will be positive three weeks after acute onset, while at the seventeen week mark only 10%
will remain positive. There is evidence of a “window” stage where the hepatitis B surface antigen has become negative and the patient has not yet developed the
hepatitis B surface antibody. The chronic carrier state is indicated by the persistence of hepatitis B surface antigen over six months and longer (even years) while
never seroconverting to hepatitis B surface antibody. The reference range is negative. The detection of the hepatitis B surface antigen establishes the presence of
infection and implies infectivity.
ICD-9-CM Codes that Support Medical Necessity The Hepatitis B surface antigen (HBsAg) is determined to be medically necessary by Medicare only when it is
ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code
to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for
that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided.
070.20 - 070.23
070.30 - 070.33
070.6
070.9
403.01
403.11
404.02
404.03
404.12
404.13
VIRAL HEPATITIS B WITH HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA - CHRONIC VIRAL
HEPATITIS B WITH HEPATIC COMA WITH HEPATITIS DELTA
VIRAL HEPATITIS B WITHOUT HEPATIC COMA ACUTE OR UNSPECIFIED WITHOUT HEPATITIS DELTA – CHRONIC
VIRAL HEPATITIS B WITHOUT HEPATIC COMA WITH HEPATITIS DELTA
UNSPECIFIED VIRAL HEPATITIS WITH HEPATIC COMA
UNSPECIFIED VIRAL HEPATITIS WITHOUT HEPATIC COMA
HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR
HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE
RENAL DISEASE
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC
KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC
KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY
DISEASE STAGE V OR END STAGE RENAL DISEASE
Note: Billing for Hepatitis B
Surface Antigen for ESRD
beneficiaries requires dual
diagnoses. Please submit codes
403.01, 403.11, 404.02, 404.03,
404.12, 404.13, or 585.4-585.6
and *V45.1 to report the
approved indication.
* According to the ICD-9-CM
book, Diagnosis code V45.1 is a
secondary diagnosis code and
should not be billed as the
primary diagnosis.
Last Updated:
12/5/13
CPT Code 87340
446.0
570
573.1
573.2
573.3
585.4
585.5
585.6
719.40 - 719.49
729.1
774.4
780.60
780.61
780.63
780.66
780.79
782.1
782.4
POLYARTERITIS NODOSA
ACUTE AND SUBACUTE NECROSIS OF LIVER
HEPATITIS IN VIRAL DISEASES CLASSIFIED ELSEWHERE
HEPATITIS IN OTHER INFECTIOUS DISEASES CLASSIFIED ELSEWHERE
HEPATITIS UNSPECIFIED
PAIN IN JOINT SITE UNSPECIFIED - PAIN IN JOINT INVOLVING MULTIPLE SITES
MYALGIA AND MYOSITIS UNSPECIFIED
PERINATAL JAUNDICE DUE TO HEPATOCELLULAR DAMAGE
FEVER, UNSPECIFIED
FEVER PRESENTING WITH CONDITIONS CLASSIFIED ELSEWHERE
POSTVACCINATION FEVER
FEBRILE NONHEMOLYTIC TRANSFUSION REACTION
OTHER MALAISE AND FATIGUE
RASH AND OTHER NONSPECIFIC SKIN ERUPTION
JAUNDICE UNSPECIFIED NOT OF NEWBORN
diagnoses. Please submit
codes 403.01, 403.11,
404.02, 404.03, 404.12,
404.13, or 585.4-585.6 and
*V45.1 to report the
* According to the ICD-9CM book, Diagnosis code
V45.1 is a secondary
diagnosis code and should
not be billed as the primary
diagnosis.
Last Updated:
12/5/13
CPT Code 87340
783.0
787.02
789.1
790.4
791.9
792.1
V01.71 - V01.79
V02.61
V45.11*
ANOREXIA
NAUSEA ALONE
HEPATOMEGALY
NONSPECIFIC ELEVATION OF LEVELS OF TRANSAMINASE OR LACTIC ACID DEHYDROGENASE (LDH)
OTHER NONSPECIFIC FINDINGS ON EXAMINATION OF URINE
NONSPECIFIC ABNORMAL FINDINGS IN STOOL CONTENTS
CONTACT OR EXPOSURE TO VARICELLA - CONTACT OR EXPOSURE TO OTHER VIRAL DISEASES
CARRIER OR SUSPECTED CARRIER OF HEPATITIS B
diagnoses. Please submit
codes 403.01, 403.11,
404.02, 404.03, 404.12,
404.13, or 585.4-585.6 and
*V45.1 to report the
* According to the ICD-9CM book, Diagnosis code
V45.1 is a secondary
diagnosis code and should
not be billed as the primary
diagnosis.
Last Updated:
12/5/13
Ionized Calcium (L29206)
CPT Code 82330
LCD Description: The bulk of body calcium (98%-99%) is stored in the skeleton and teeth, which act as huge reservoirs for maintaining the blood levels
of calcium. Ionized calcium is a cation that circulates freely in the bloodstream and comprises 46-50% of all circulating calcium. Only the ionized calcium
can be used by the body in such vital processes as muscular contraction, cardiac function, transmission of nerve impulses, and blood clotting. Ionized
calcium is considered a more sensitive and accurate indicator for many operative procedures and disease processes. A normal serum ionized calcium for
an adult is 4.65 - 5.28 mg/dl.
ICD-9-CM Codes that Support Medical Necessity The Ionized Calcium test is determined to be medically necessary by Medicare only when it is
procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable
and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s). This list
was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a complete reference.
038.0 - 038.9
252.00 - 252.08
252.1
259.3
275.2
275.41
275.42
275.49
278.4
293.83
298.9
458.9
577.0
577.1
585.1 - 585.9
586
588.81 - 588.89
733.90
780.60
STREPTOCOCCAL SEPTICEMIA - UNSPECIFIED SEPTICEMIA
HYPERPARATHYROIDISM, UNSPECIFIED - OTHER HYPERPARATHYROIDISM
HYPOPARATHYROIDISM
ECTOPIC HORMONE SECRETION NOT ELSEWHERE CLASSIFIED
DISORDERS OF MAGNESIUM METABOLISM
HYPOCALCEMIA
HYPERCALCEMIA
OTHER DISORDERS OF CALCIUM METABOLISM
HYPERVITAMINOSIS D
MOOD DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
UNSPECIFIED PSYCHOSIS
HYPOTENSION UNSPECIFIED
ACUTE PANCREATITIS
CHRONIC PANCREATITIS
CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE,
UNSPECIFIED
RENAL FAILURE UNSPECIFIED
SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) –
OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED RENAL FUNCTION
DISORDER OF BONE AND CARTILAGE UNSPECIFIED
FEVER, UNSPECIFIED
780.61
780.62
780.63
780.66
780.79
781.0
781.7
782.4
785.0
786.06
787.01 - 787.04
787.20 - 787.29
788.42
789.06
996.81
V42.0*
V45.11*
V56.0
FEVER PRESENTING WITH CONDITIONS
CLASSIFIED ELSEWHERE
POSTPROCEDURAL FEVER
POSTVACCINATION FEVER
FEBRILE NONHEMOLYTIC TRANSFUSION
REACTION
ABNORMAL INVOLUNTARY MOVEMENTS
TETANY
JAUNDICE UNSPECIFIED NOT OF NEWBORN
TACHYCARDIA UNSPECIFIED
TACHYPNEA
NAUSEA WITH VOMITING - BILIOUS EMESIS
DYSPHAGIA, UNSPECIFIED - OTHER DYSPHAGIA
POLYURIA
ABDOMINAL PAIN EPIGASTRIC
COMPLICATIONS OF TRANSPLANTED KIDNEY
KIDNEY REPLACED BY TRANSPLANT
AFTERCARE INVOLVING EXTRACORPOREAL
DIALYSIS
*According to the ICD-9 CM Book, Diagnosis codes V42.0 and V45.11 are secondary diagnosies codes. These should be billed alone. A primary
Diagnosis code should be billed in addition to the secondary diagnoses codes.
Last Updated:
12/5/13
Magnesium (L29217) 1 of 3
CPT Code 83735
LCD Description:.. Magnesium is an important activator ion, participating in the function of many enzymes involved in phosphate transfer reactions.
Most of the magnesium found within the body exists intracellularly, and since most of it is bound to adenosine triphosphate, this electrolyte is critical in nearly all metabolic
processes and most organ functions. Magnesium exerts physiologic effects on the nervous system resembling those of calcium, acting directly upon the myoneural
junction. Furthermore, magnesium acts as a cofactor that modifies the activity of many enzymes. Carbohydrate, protein, and nucleic acid metabolism depend on
magnesium. Excretion of magnesium is via the kidney, and altered concentration of magnesium in the plasma usually provokes an associated alteration of calcium and
potassium. The normal plasma concentration of magnesium is 1.5-2.5 meq/L, with about one-third bound to protein and two-thirds existing as free cation.
ICD-9-CM Codes that Support Medical Necessity: The Magnesium test is determined to be medically necessary by Medicare only when it is ordered for patients with
one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM
code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation
within the patient’s medical record must support the medical necessity for the test(s) provided.
242.00 - 242.91
250.10 - 250.13
250.20 - 250.23
250.30 - 250.33
250.40 - 250.43
250.50 - 250.53
250.60 - 250.63
250.70 - 250.73
250.80 – 250.83
TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM
THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC
CRISIS OR STORM
DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, NOT
252.00 – 252.08
STATED AS UNCONTROLLED - DIABETES WITH KETOACIDOSIS,
252.8
TYPE I [JUVENILE TYPE], UNCONTROLLED
253.6
DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE,
255.10 - 255.14
NOT STATED AS UNCONTROLLED - DIABETES WITH HYPEROSMOLARITY
TYPE [JUVENILE TYPE], UNCONTROLLED
255.41
DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE,
255.42
NOT STATED AS UNCONTROLLED - DIABETES WITH OTHER COMA,
259.3
DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE,
NOT STATED AS UNCONTROLLED - DIABETES WITH RENAL MANIFESTATIONS, 260
261
262
DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR
263.0
UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH
263.8
OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED
275.2
DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR
275.40 - 275.49
UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES
WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE],
276.2
UNCONTROLLED
276.4
DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR
276.50 - 276.52
UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH
276.7 – 276.8
PERIPHERALCIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE],
293.0, 293.1
UNCONTROLLED
DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE ii
OR UNSPECIFIED TYPE, NOT STATED, NOT CONTROLLED
DIABETES WITH OTHER MANIFESTATIONS, TYPE I [JUVENILE],
UNCONTROLLED
HYPOPARATHYROIDISM
OTHER SPECIFIED DISORDERS OF PARATHYROID GLAND
OTHER DISORDERS OF NEUROHYPOPHYSIS
HYPERALDOSTERONISM, UNSPECIFIED - OTHER
SECONDARY ALDOSTERONISM
GLUCOCORTICOID DEFICIENCY
MINERALOCORTICOID DEFICIENCY
ECTOPIC HORMONE SECRETION NOT ELSEWHERE
CLASSIFIED
KWASHIORKOR
NUTRITIONAL MARASMUS
OTHER SEVERE PROTEIN-CALORIE MALNUTRITION
MALNUTRITION OF MODERATE DEGREE
OTHER PROTEIN-CALORIE MALNUTRITION
UNSPECIFIED DISORDER OF CALCIUM METABOLISM
ACIDOSIS
MIXED ACID-BASE BALANCE DISORDER
VOLUME DEPL
HYPERPOTASSEMIA
DELIRIUM
* According to the ICD-9-CM book, Diagnosis codes V42.0, V42.7 and V58.69 are secondary diagnosis codes and should not be billed as the primary diagnosis.
Last Updated:
12/5/13
CPT Code 83735
579.3
579.8
584.5 - 584.9
585.1 - 585.9
588.81 - 588.89
593.81
643.00 - 643.83
646.80 - 646.84
728.87
728.88
728.89
763.81 - 763.89
780.01
780.02
780.09
780.2
780.31 - 780.39
OTHER AND UNSPECIFIED POSTSURGICAL NONABSORPTION
OTHER SPECIFIED INTESTINAL MALABSORPTION
ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS
ACUTE KIDNEY FAILURE, UNSPECIFIED
CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE
UNSPECIFIED
SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN)
OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED
RENAL FUNCTION
VASCULAR DISORDERS OF KIDNEY
MILD HYPEREMESIS GRAVIDARUM UNSPECIFIED AS TO EPISODE
OF CARE - OTHER VOMITING COMPLICATING PREGNANCY ANTEPARTUM
OTHER SPECIFIED COMPLICATIONS OF PREGNANCY UNSPECIFIED
AS TO EPISODE OF CARE - OTHER SPECIFIED POSTPARTUM
COMPLICATIONS
MUSCLE WEAKNESS (GENERALIZED)
RHABDOMYOLYSIS
OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA
ABNORMALITY IN FETAL HEART RATE OR RHYTHM BEFORE
THE ONSET OF LABOR - OTHER SPECIFIED COMPLICATIONS OF
LABOR AND DELIVERY
AFFECTING FETUS OR NEWBORN
COMA
TRANSIENT ALTERATION OF AWARENESS
ALTERATION OF CONSCIOUSNESS OTHER
SYNCOPE AND COLLAPSE
FEBRILE CONVULSIONS (SIMPLE), UNSPECIFIED - OTHER CONVULSIONS
781.0
781.7
783.0
785.0
785.50 - 785.59
787.01 - 787.04
787.91
790.6
794.31
794.4
796.1
799.4
940.0 - 949.5
958.4
995.29
997.1
998.00 - 998.09
V42.0*
V42.7*
V56.0
V56.8
TETANY
ANOREXIA
TACHYCARDIA UNSPECIFIED
SHOCK UNSPECIFIED - OTHER SHOCK WITHOUT TRAUMA
DIARRHEA
OTHER ABNORMAL BLOOD CHEMISTRY
NONSPECIFIC ABNORMAL ELECTROCARDIOGRAM
(ECG) (EKG)
NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY
OF KIDNEY
ABNORMAL REFLEX
CACHEXIA
CHEMICAL BURN OF EYELIDS AND PERIOCULAR AREA
DEEP NECROSIS OF UNDERLYING
ISSUES DUE TO BURN (DEEP THIRD DEGREE UNSPECIFIED
SITE WITH LOSS OF A BODY PART
TRAUMATIC SHOCK
UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG,
MEDICINAL AND BIOLOGICAL SUBSTANCE
CARDIAC COMPLICATIONS NOT ELSEWHERE CLASSIFIED
POSTOPERATIVE SHOCK, UNSPECIFIED – POSTOPERATIVE
SHOCK, OTHER
LIVER REPLACED BY TRANSPLANT
AFTERCARE INVOLVING EXTRACORPOREAL DIALYSIS
AFTERCARE INVOLVING OTHER DIALYSIS
Last Updated:
12/5/13
CPT Code 83735
303.90 - 303.93
305.00 - 305.03
307.1
307.51
307.52
333.2
333.3
410.00 - 410.92
424.0
427.0 - 427.89
428.0
458.0 - 458.8
536.2
569.87
577.0 - 577.9
781.7
V56.8
V58.11
V58.69*
OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE UNSPECIFIED
DRINKING BEHAVIOR - OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE IN REMISSION
NONDEPENDENT ALCOHOL ABUSE UNSPECIFIED DRINKING BEHAVIOR
NONDEPENDENT ALCOHOL ABUSE IN REMISSION
ANOREXIA NERVOSA
BULIMIA NERVOSA
PICA
MYOCLONUS
TICS OF ORGANIC ORIGIN
ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED
ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE
MITRAL VALVE DISORDERS
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - OTHER SPECIFIED CARDIAC DYSRHYTHMIAS
CONGESTIVE HEART FAILURE UNSPECIFIED
ORTHOSTATIC HYPOTENSION - OTHER SPECIFIED HYPOTENSION
PERSISTENT VOMITING
VOMITING OF FECAL MATTER
ACUTE PANCREATITIS - UNSPECIFIED DISEASE OF PANCREAS
TETANY
AFTERCARE INVOLVING OTHER DIALYSIS
ENCOUNTER FOR ANTINEOPLASTIC CHEMOTHERAPY
LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
* According to the ICD-9-CM book, Diagnosis codes V42.0, V42.7 and V58.69 are secondary diagnosis codes and should not be billed as the primary diagnosis.
Last Updated:
12/5/13
Non-Covered ICD-9-CM Codes for All NCD Edits
Florida
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.
798.0 - 798.9
V18.51
V60.81
V74.0 - V74.9
V77.2 - V77.99
V15.85
V18.59
V60.89
V75.0 - V75.9
V78.0 - V78.9
V16.1
V18.61
V60.9
V76.0
V79.0 - V79.9
V16.2
V18.69
V62.0 – V62.1
V76.3
V80.01
V16.40
V18.7 - V18.9
V65.0
V76.42 - V76.43
V80.09
V16.50 - V16.59
V19.0 - V19.8
V65.11
V76.45 - V76.47
V80.1 - V80.3
V16.6
V20.0 - V20.2
V65.19
V76.49
V81.3 - V81.6
V16.7
V20.31-V20.32
V68.0 - V68.9
V76.50
V82.0 - V82.6
V16.8
V28.0 - V28.9
V70.0 - V70.9
V76.52
V82.71
V16.9
V50.0 - V50.9
V73.0 - V73.6
V76.81
V82.79
V17.0 - V17.89
V53.2
V73.81
V76.89
V82.81
V18.0 – V18.4
V60.0 –V60.6
V73.88 - V73.89
V76.9
V82.89
V73.98 – V73.99
V77.0
V82.9
Last Updated:
12/6/13
Parathormone, (Parathyroid Hormone) (L29251) 1 of 2
CPT Code 83970
LCD Description:. Normally, PTH release is regulated by a negative feedback mechanism involving serum calcium. Normal or
elevated circulating calcium (especially the ionized form) inhibits PTH release; a decrease in calcium ions stimulates PTH release. The overall effect of
PTH is to raise plasma levels of calcium while lowering phosphorus levels by stimulating osteoclasts and osteocytes to mobilize both calcium and
phosphorus from bone; by acting on renal tubular cells to promote calcium reabsorption and phosphorus excretion; and by promoting intestinal
absorption of calcium.
There are three molecular forms of PTH: (1) intact, also called native or glandular hormone; (2) multiple NH2-terminal fragments; and (3) COOHterminal fragments. Different laboratories assay the three different parts of the PTH molecule. The intact hormone assay most clearly differentiates
hyperparathyroidism from nonparathyroid hypercalcemia. The N-terminal (mid-region) fragment contains the active portion of the molecule, but these
assays may not measure intact hormone. The C-terminal fragment contains an inactive portion of the molecule; it is the next best choice of assays if the
intact hormone assay is not available. The C-terminal fragment is the oldest and most widely available assay. Normal serum PTH levels vary,
depending on the laboratory but are typically as follows: Intact PTH: 10 to 65 pg/ml; N-terminal fraction: 8 to 24 pg/ml; and C-terminal fraction: 0 to 340
pg/ml.
The PTH is normally measured concomitantly with serum calcium levels. Abnormally elevated PTH values may indicate primary, secondary, or tertiary
hyperparathyroidism. Abnormally low PTH levels may result from hypoparathyroidism and from certain malignant diseases such as squamous cell
carcinoma of the lung, renal carcinoma, pancreatic carcinoma, or ovarian carcinoma
ICD-9-CM Codes that Support Medical Necessity The Parathormone (Parathyroid Hormone) is determined to be medically necessary by Medicare
only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not
enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure
must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity
for the test(s) provided.
227.1
252.00 - 252.08
252.1
259.3
275.2
275.3
275.41
275.42
275.49
BENIGN NEOPLASM OF PARATHYROID GLAND
HYPERPARATHYROIDISM, UNSPECIFIED - OTHER
HYPERPARATHYROIDISM
HYPOPARATHYROIDISM
ECTOPIC HORMONE SECRETION NOT ELSEWHERE
CLASSIFIED
DISORDERS OF PHOSPHORUS METABOLISM
HYPOCALCEMIA
HYPERCALCEMIA
278.4
293.0
293.83
585.1 - 585.9
586
588.81 - 588.89
728.85
733.00
733.01
HYPERVITAMINOSIS D
DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE
MOOD DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE
CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY
DISEASE, UNSPECIFIED
OTHER SPECIFIED DISORDERS RESULTING FROM IMPAIRED
RENAL FUNCTION
SPASM OF MUSCLE
OSTEOPOROSIS UNSPECIFIED
SENILE OSTEOPOROSIS
* According to the ICD-9-CM book, diagnosis code V42.0 is a secondary diagnosis code and should not be billed as the primary diagnosis.
Last Updated:
12/5/13
Parathormone, (Parathyroid Hormone) (L29251) 2 of 2
CPT Code 83970
LCD Description:. Normally, PTH release is regulated by a negative feedback mechanism involving serum calcium. Normal or
elevated circulating calcium (especially the ionized form) inhibits PTH release; a decrease in calcium ions stimulates PTH release. The overall effect of
PTH is to raise plasma levels of calcium while lowering phosphorus levels by stimulating osteoclasts and osteocytes to mobilize both calcium and
phosphorus from bone; by acting on renal tubular cells to promote calcium reabsorption and phosphorus excretion; and by promoting intestinal
absorption of calcium.
There are three molecular forms of PTH: (1) intact, also called native or glandular hormone; (2) multiple NH2-terminal fragments; and (3) COOHterminal fragments. Different laboratories assay the three different parts of the PTH molecule. The intact hormone assay most clearly differentiates
hyperparathyroidism from nonparathyroid hypercalcemia. The N-terminal (mid-region) fragment contains the active portion of the molecule, but these
assays may not measure intact hormone. The C-terminal fragment contains an inactive portion of the molecule; it is the next best choice of assays if the
intact hormone assay is not available. The C-terminal fragment is the oldest and most widely available assay. Normal serum PTH levels vary,
depending on the laboratory but are typically as follows: Intact PTH: 10 to 65 pg/ml; N-terminal fraction: 8 to 24 pg/ml; and C-terminal fraction: 0 to 340
pg/ml.
The PTH is normally measured concomitantly with serum calcium levels. Abnormally elevated PTH values may indicate primary, secondary, or tertiary
hyperparathyroidism. Abnormally low PTH levels may result from hypoparathyroidism and from certain malignant diseases such as squamous cell
carcinoma of the lung, renal carcinoma, pancreatic carcinoma, or ovarian carcinoma
ICD-9-CM Codes that Support Medical Necessity The Parathormone (Parathyroid Hormone) is determined to be medically necessary by Medicare
only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not
enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure
must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity
for the test(s) provided.
733.02
733.90
780.79
781.0
781.7
787.01 - 787.04
787.20 - 787.29
788.42
V42.0*
V67.00
IDIOPATHIC OSTEOPOROSIS
TETANY
POLYURIA
FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED/OTHER
SURGERY
* According to the ICD-9-CM book, diagnosis code V42.0 is a secondary diagnosis code and should not be billed as the primary diagnosis.
Last Updated:
12/5/13
Qualitative Drug Screening (L30574) 1 of 2
CPT Code 80102, G0431, and G0434
LCD Description: A qualitative drug screen reports the presence of a drug in a blood or urine specimen. A blood or urine sample may be
used. Urine is usually the preferred specimen type due to its sensitivity to many common drugs compared to blood specimens. A qualitative
drug screen may be indicated when the history is unreliable, with a multiple-drug ingestion, with a patient in delirium or coma, for the
identification of specific drugs, and to indicate when antagonists may be used.
ICD-9-CM Codes that Support Medical Necessity: Medicare will consider performance of a qualitative drug screen (HCPCS code
G0430/G0431) medically reasonable and necessary when the patient presents with suspected drug overdose or suspected drug misuse and
one or more of the following indications:
276.2
304.90
345.10
345.11
345.3
345.90
345.91
426.10
426.11
426.12
426.13
426.82
427.0
427.1
518.81
780.01
780.09
780.39
963.0
965.00
ACIDOSIS
UNSPECIFIED DRUG DEPENDENCE UNSPECIFIED USE
GENERALIZED CONVULSIVE EPILEPSY
WITHOUT INTRACTABLE EPILEPSY
GENERALIZED CONVULSIVE EPILEPSY WITH
INTRACTABLE EPILEPSY
GRAND MAL STATUS EPILEPTIC
EPILEPSY UNSPECIFIED WITHOUT INTRACTABLE EPILEPSY
EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY
ATRIOVENTRICULAR BLOCK UNSPECIFIED
FIRST DEGREE ATRIOVENTRICULAR BLOCK
MOBITZ (TYPE) II ATRIOVENTRICULAR BLOCK
OTHER SECOND DEGREE ATRIOVENTRICULAR BLOCK
LONG QT SYNDROME
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
PAROXYSMAL VENTRICULAR TACHYCARDIA
ACUTE RESPIRATORY FAILURE
COMA
OTHER CONVULSIONS
POISONING BY ANTIALLERGIC AND ANTIEMETIC DRUGS
POISONING BY OPIUM (ALKALOIDS) UNSPECIFIED
965.01
965.02
965.09
965.1
965.4
POISONING BY HEROIN
POISONING BY METHADONE
POISONING BY OTHER OPIATES AND RELATED NARCOTICS
POISONING BY AROMATIC ANALGESICS
NOT ELSEWHERE CLASSIFIED
965.5
POISONING BY PYRAZOLE DERIVATIVES
965.61
POISONING BY PROPIONIC ACID DERIVATIVES
966.1
POISONING BY HYDANTOIN DERIVATIVES
967.0
POISONING BY BARBITURATES
967.1
POISONING BY CHLORAL HYDRATE GROUP
967.2
POISONING BY PARALDEHYDE
967.3
POISONING BY BROMINE COMPOUNDS
967.4
POISONING BY METHAQUALONE COMPOUNDS
967.5
POISONING BY GLUTETHIMIDE GROUP
967.6
POISONING BY MIXED SEDATIVES NOT ELSEWHERE CLASSIFIED
967.8
POISONING BY OTHER SEDATIVES AND HYPNOTICS
967.9
POISONING BY UNSPECIFIED SEDATIVE OR HYPNOTIC
969.00 - 969.09 POISONING BY ANTIDEPRESSANT, UNSPECIFIED - POISONING
BY OTHER ANTIDEPRESSANTS
969.1
POISONING BY PHENOTHIAZINE-BASED TRANQUILIZERS
969.2
POISONING BY BUTYROPHENONE-BASED TRANQUILIZERS
*Although designated by the American Association (AMA) as supplementary codes for the purposes of this FCSC Medicare will not require a primary ICD 9 CM code
When using V15.81 and V58.69 to bill for approved indication
Last Updated:
12/5/13
Qualitative Drug Screening (L30574) 2 of 2
CPT Code 80102, G0431 and G0434
LCD Description: A qualitative drug screen reports the presence of a drug in a blood or urine specimen. A blood or urine sample may be
used. Urine is usually the preferred specimen type due to its sensitivity to many common drugs compared to blood specimens. A qualitative
drug screen may be indicated when the history is unreliable, with a multiple-drug ingestion, with a patient in delirium or coma, for the
identification of specific drugs, and to indicate when antagonists may be used.
ICD-9-CM Codes that Support Medical Necessity: Medicare will consider performance of a qualitative drug screen (HCPCS code
G0430/G0431) medically reasonable and necessary when the patient presents with suspected drug overdose or suspected drug misuse and
one or more of the following indications:
969.3
969.4
969.5
969.6
969.70 - 969.79
969.8
969.9
970.81 - 970.89
972.1
977.9
V15.81*
V58.69*
V71.09
POISONING BY OTHER ANTIPSYCHOTICS NEUROLEPTICS AND MAJOR TRANQUILIZERS
POISONING BY BENZODIAZEPINE-BASED TRANQUILIZERS
POISONING BY OTHER TRANQUILIZERS
POISONING BY PSYCHODYSLEPTICS (HALLUCINOGENS)
POISONING BY PSYCHOSTIMULANT, UNSPECIFIED - POISONING BY OTHER PSYCHOSTIMULANTS
POISONING BY OTHER SPECIFIED PSYCHOTROPIC AGENTS
POISONING BY UNSPECIFIED PSYCHOTROPIC AGENT
POISONING BY COCAINE - POISONING BY OTHER CENTRAL NERVOUS SYSTEM STIMULANTS
POISONING BY CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION
POISONING BY UNSPECIFIED DRUG OR MEDICINAL SUBSTANCE
PERSONAL HISTORY OF NONCOMPLIANCE WITH MEDICAL TREATMENT PRESENTING HAZARDS TO HEALTH
LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS
OBSERVATION OF OTHER SUSPECTED MENTAL CONDITION
*Although designated by the American Association (AMA) as supplementary codes for the purposes of this FCSC Medicare will not require a primary ICD 9 CM code
When using V15.81 and V58.69 to bill for approved indication
Last Updated:
12/5/2013
Sedimentation Rate, Erythrocyte (L29277) 1 of 2
LCD Description(85651):.The erythrocyte sedimentation rate (ESR) is a sensitive but nonspecific test that is frequently the earliest
indicator of disease when other chemical or physical signs are normal. It is most often used as a gauge for determining the progress and detection of an
inflammatory disorder caused by infection, autoimmune mechanisms, or connective tissue disease.
LCD Description(85652):.. The frequency with which hepatic function is tested depends upon the clinical situation and generally, upon the time during
which a significant (relevant to treatment) change in hepatic function is expected to occur.
ICD-9-CM Codes that Support Medical Necessity: The Sedimentation Rate, Erythrocyte test is determined to be medically necessary by Medicare only
when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to
link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be
test(s) provided.
200.20 - 200.28
201.00 - 201.98
202.00 - 202.08
202.80 - 202.88
240.0 - 240.9
241.0 - 241.9
242.00 - 242.91
245.0 - 245.9
246.8
279.41 - 279.49
285.29
285.9
362.34
379.91
391.0
391.1
BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE - BURKITT'S
TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S DISEASE
UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES
NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA
INVOLVING LYMPH NODES OF MULTIPLE SITES
OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER
MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES
GOITER SPECIFIED AS SIMPLE - GOITER UNSPECIFIED
NONTOXIC UNINODULAR GOITER – UNSPECIFIED
NONTOXIC NODULAR GOITER
TOXIC DIFFUSE GOITER WITHOUT THYROTOXIC CRISIS OR STORM
THYROTOXICOSIS WITHOUT GOITER OR OTHER CAUSE WITH THYROTOXIC
CRISIS OR STORM
ACUTE THYROIDITIS - THYROIDITIS UNSPECIFIED
OTHER SPECIFIED DISORDERS OF THYROID
AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME - AUTOIMMUNE
DISEASE, NOT ELSEWHERE CLASSIFIED
ANEMIA OF OTHER CHRONIC DISEASE
ANEMIA UNSPECIFIED
TRANSIENT RETINAL ARTERIAL OCCLUSION
PAIN IN OR AROUND EYE
ACUTE RHEUMATIC PERICARDITIS
ACUTE RHEUMATIC ENDOCARDITIS
391.2
391.8
410.00 - 410.92
446.0
446.5
447.6
556.0 - 556.9
696.0
710.0
710.1
710.2
710.4
710.9
714.0
ACUTE RHEUMATIC MYOCARDITIS
OTHER ACUTE RHEUMATIC HEART DISEASE
ACUTE MYOCARDIAL INFARCTION OF
ANTEROLATERAL
WALL EPISODE OF CARE UNSPECIFIEDACUTE MYOCARDIAL
INFARCTION OF UNSPECIFIED SITE
SUBSEQUENT
EPISODE OF CARE
POLYARTERITIS NODOSA
GIANT CELL ARTERITIS
ARTERITIS UNSPECIFIED
ULCERATIVE (CHRONIC) ENTEROCOLITIS
VULCERATIVE COLITIS UNSPECIFIED
PSORIATIC ARTHROPATHY
SYSTEMIC LUPUS ERYTHEMATOSUS
SYSTEMIC SCLEROSIS
SICCA SYNDROME
POLYMYOSITIS
UNSPECIFIED DIFFUSE CONNECTIVE
TISSUE DISEASE
RHEUMATOID ARTHRITIS
*According to the ICD 9-CM Book, diagnosis codes E933.1, E935.6 and E947.2 are secondary diagnosis and must not be billed as the primary diagnosis
Last Updated:
12/5/14
Sedimentation Rate, Erythrocyte (L29277) 2 of 2
LCD Description(85651):.The erythrocyte sedimentation rate (ESR) is a sensitive but nonspecific test that is frequently the earliest
indicator of disease when other chemical or physical signs are normal. It is most often used as a gauge for determining the progress and detection of an
inflammatory disorder caused by infection, autoimmune mechanisms, or connective tissue disease.
LCD Description(85652):.. The frequency with which hepatic function is tested depends upon the clinical situation and generally, upon the time during
which a significant (relevant to treatment) change in hepatic function is expected to occur.
ICD-9-CM Codes that Support Medical Necessity: The Sedimentation Rate, Erythrocyte test is determined to be medically necessary by Medicare only
when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to
link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be
test(s) provided.
714.1
714.2
714.30
714.81
714.9
716.59
719.49
720.0
725
729.1
733.99
783.21
784.0
E933.1*
E933.8*
E935.6*
E947.2*
V10.72
FELTY'S SYNDROME
OTHER RHEUMATOID ARTHRITIS WITH VISCERAL OR SYSTEMIC INVOLVEMENT
CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS
RHEUMATOID LUNG
UNSPECIFIED INFLAMMATORY POLYARTHROPATHY
UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING MULTIPLE SITES
PAIN IN JOINT INVOLVING MULTIPLE SITES
ANKYLOSING SPONDYLITIS
POLYMYALGIA RHEUMATICA
OTHER DISORDERS OF BONE AND CARTILAGE
LOSS OF WEIGHT
HEADACHE
ANTINEOPLASTIC AND IMMUNOSUPPRESSIVE DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
OTHER SYSTEMIC AGENTS NOT ELSEWHERE CLASSIFIED CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
ANTIRHEUMATICS (ANTIPHLOGISTICS) CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
ANTIDOTES AND CHELATING AGENTS NOT ELSEWHERE CLASSIFIED CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
PERSONAL HISTORY OF HODGKIN'S DISEASE
*According to the ICD 9-CM Book, diagnosis codes E933.1, E935.6 and E947.2 are secondary diagnosis and must not be billed as the primary diagnosis
Last Updated:
12/5/13
Serum Phosphorus 1 of 4 (L29278)
CPT Code 84100
LCD Description: Phosphorus is a non-metallic chemical element. Most of the body’s phosphorus is combined with calcium within the skeleton;
however, approximately 15% of phosphorus exists in the blood as a phosphate salt. Phosphates help store and utilize body energy. Additionally, they
help regulate calcium levels, carbohydrate and lipid metabolism, and acid-base balance. Vitamin D is important in the absorption and metabolism of
phosphorus. Phosphorus levels are determined by calcium metabolism, parathyroid hormone, and to a lesser degree by intestinal absorption. Normal
serum phosphorus is 2.5-4.5 mg/dl. Serum phosphate levels help to detect endocrine, skeletal, and calcium disorders, and aid in the diagnosis of renal
disorders and acid-base imbalance.
ICD-9-CM Codes that Support Medical Necessity: The Serum Phosphorus test is determined to be medically necessary by Medicare only when it is
test(s) provided.
135
170.0 - 170.9
198.5
203.00 - 203.02
238.6
252.00 - 252.08
260
261
262
263.0 - 263.9
268.0 - 268.9
275.2
275.3
275.40 - 275.49
293.1
298.9
348.30 - 348.39
276.0 - 276.9
278.4
278.8
283.9
287.0 - 287.9
SARCOIDOSIS
MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE - MALIGNANT NEOPLASM OF BONE AND
ARTICULAR CARTILAGE SITE UNSPECIFIED
SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW
MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MULTIPLE MYELOMA, IN RELAPSE
NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS
HYPERPARATHYROIDISM, UNSPECIFIED - OTHER HYPERPARATHYROIDISM
KWASHIORKOR
NUTRITIONAL MARASMUS
OTHER SEVERE PROTEIN-CALORIE MALNUTRITION
MALNUTRITION OF MODERATE DEGREE - UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
RICKETS ACTIVE - UNSPECIFIED VITAMIN D DEFICIENCY
UNSPECIFIED DISORDER OF CALCIUM METABOLISM - OTHER DISORDERS OF CA293.0
SUBACUTE DELIRIUM
ENCEPHALOPATHY UNSPECIFIED - OTHER ENCEPHALOPATHYLCIUM METABOLISM
HYPEROSMOLALITY AND/OR HYPERNATREMIA - ELECTROLYTE AND FLUID DISORDERS NOT ELSEWHERE CLASSIFIED
HYPERVITAMINOSIS D
OTHER HYPERALIMENTATION
ACQUIRED HEMOLYTIC ANEMIA UNSPECIFIED
ALLERGIC PURPURA - UNSPECIFIED HEMORRHAGIC CONDITIONS
Last Updated:
12/5/13
CPT Code 84100
test(s) provided.
293.0
293.1
298.9
348.30 - 348.39
403.01
403.11
404.02
404.03
404.12
404.13
579.0 - 579.9
580.0 - 580.9
581.0 - 581.9
582.0 - 582.9
SUBACUTE DELIRIUM
ENCEPHALOPATHY UNSPECIFIED - OTHER ENCEPHALOPATHY
HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE
STAGE V OR END STAGE RENAL DISEASE
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V
HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V
CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION
ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - ACUTE GLOMERULONEPHRITIS WITH
UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHROTIC SYNDROME WITH UNSPECIFIED
PATHOLOGICAL LESION IN KIDNEY
CHRONIC GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - CHRONIC GLOMERULONEPHRITIS
WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
Last Updated:
12/5/13
CPT Code 84100
test(s) provided.
583.0 - 583.9
584.5 - 584.9
585.1 - 585.9
586
587
588.0 - 588.9
646.90
728.87
728.88
728.89
728.9
729.1
731.0
733.90
753.9
780.39
782.0
783.0
787.02
790.6
790.7
NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS - NEPHRITIS AND
NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS - ACUTE KIDNEY FAILURE, UNSPECIFIED
CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED
RENAL SCLEROSIS UNSPECIFIED
RENAL OSTEODYSTROPHY - UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION
UNSPECIFIED COMPLICATION OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE
RHABDOMYOLYSIS
UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA
OSTEITIS DEFORMANS WITHOUT BONE TUMOR
DISORDER OF BONE AND
CARTILAGE UNSPECIFIED
UNSPECIFIED CONGENITAL ANOMALY OF URINARY SYSTEM
OTHER CONVULSIONS
DISTURBANCE OF SKIN SENSATION
ANOREXIA
NAUSEA ALONE
OTHER ABNORMAL BLOOD CHEMISTRY
BACTEREMIA
Last Updated:
12/5/13
CPT Code 84100
test(s) provided.
793.0
793.7
799.21
799.22
799.51
799.52
799.54
799.55
965.1
990
995.84
E858.5*
E933.3*
E943.0*
E944.0 - E944.7*
V45.89*
NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD
NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF MUSCULOSKELETAL SYSTEM
NERVOUSNESS
IRRITABILITY
ATTENTION OR CONCENTRATION DEFICIT
COGNITIVE COMMUNICATION DEFICIT
PSYCHOMOTOR DEFICIT
FRONTAL LOBE AND EXECUTIVE FUNCTION DEFICIT
EFFECTS OF RADIATION UNSPECIFIED
ADULT NEGLECT (NUTRITIONAL)
ACCIDENTAL POISONING BY WATER MINERAL AND URIC ACID METABOLISM DRUGS
ALKALIZING AGENTS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
ANTACIDS AND ANTIGASTRIC SECRETION DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
MERCURIAL DIURETICS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE - URIC ACID METABOLISM
DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
OTHER POSTSURGICAL STATUS
* According to the ICD-9-CM book, Diagnosis codes E858.5, E933.3, E943.0, E944.0-E944.7 and V45.89 are secondary diagnosis codes and should not be
billed as the primary diagnosis.
Last Updated:
12/5/13
07/19/11
Medicare Local Coverage Determination Policy Florida
Susceptibility Studies (L29319)
CPT Code 87181, 87184, 87185, 87186, 87187, 87188 and 87190
LCD Description: Some microorganisms are resistant to certain antimicrobials. Susceptibility testing is often used to determine the likelihood that a particular drug
treatment regimen will be effective in eliminating or inhibiting the growth of the infection. A culture of the infected area must be done to obtain the organism for
identification and to allow susceptibility testing to be performed if warranted. Referred to by the type of body fluid or cells collected (such as: blood culture, urine culture,
sputum culture, wound culture, etc.), the culture involves incubating a sample at body temperature in a nutrient-rich environment. This process promotes the replication
of any microorganisms present in the sample. Samples from the skin, stool, or sputum will grow normal flora as well as pathogenic bacteria if they are present. Other
body samples, such as blood and urine, are usually sterile; they will show little or no growth unless a pathogenic microorganism is present.
ICD-9-CM Codes that Support Medical Necessity:
The Susceptibility studies test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present
for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must
support the medical necessity for the test(s) provided.
001.0 - 009.3
CHOLERA DUE TO VIBRIO CHOLERAE - DIARRHEA OF PRESUMED INFECTIOUS ORIGIN
010.00 - 018.96
PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - UNSPECIFIED MILIARY TUBERCULOSIS TUBERCLE BACILLI NOT
FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS
(INOCULATION OF ANIMALS)
020.0 - 027.9
BUBONIC PLAGUE - UNSPECIFIED ZOONOTIC BACTERIAL DISEASE
030.0 - 041.9
LEPROMATOUS LEPROSY (TYPE L) - BACTERIAL INFECTION UNSPECIFIED IN CONDITIONS CLASSIFIED ELSEWHERE AND OF
UNSPECIFIED SITE
090.0 - 099.9
EARLY CONGENITAL SYPHILIS SYMPTOMATIC - VENEREAL DISEASE UNSPECIFIED
100.0 - 104.9
LEPTOSPIROSIS ICTEROHEMORRHAGICA - SPIROCHETAL INFECTION UNSPECIFIED
110.0 - 118
DERMATOPHYTOSIS OF SCALP AND BEARD - OPPORTUNISTIC MYCOSES
136.8
OTHER SPECIFIED INFECTIOUS AND PARASITIC DISEASES
139.8
LATE EFFECTS OF OTHER AND UNSPECIFIED INFECTIOUS AND PARASITIC DISEASES
V09.80 - V09.81*
INFECTION WITH MICROORGANISMS RESISTANT TO OTHER SPECIFIED DRUGS WITHOUT RESISTANCE TO MULTIPLE DRUGS INFECTION WITH MICROORGANISMS RESISTANT TO OTHER SPECIFIED DRUGS WITH RESISTANCE TO MULTIPLE DRUGS
*According to the ICD-9 CM Book, diagnosis codes V09.80 and V09.81 are secondary diagnosis codes and should not be billed as the primary diagnosis.
Last Updated:
12/5/13
Syphilis (L29416) 1 of 2
CPT Codes 86592, 86593 and 86780
LCD Description: The fluorescent treponemal antibody absorption (FTA-abs) test is the most widely employed treponemal test. It is a specific test for
the diagnosis of syphilis. The FTA-abs test includes a serum specimen which is absorbed and then tested with immunofluorescence for the antibody to
Treponema pallidum, the causative agent of syphilis.
FTA-abs is the most sensitive test in all stages of syphilis. The FTA-abs test is of value principally in determining whether a positive nontreponemal
antigen test (e.g., Rapid Plasma Reagin [RPR] or Venereal Disease Research Laboratory [VDRL]) is “false positive” or is indicative of syphilis. Because
of its great sensitivity, particularly in the late stages of the disease, the FTA-abs test is also of value when there is clinical evidence of syphilis but the
nontreponemal serologic test for syphilis is negative. The test is positive in most patients with primary syphilis and in virtually all with secondary syphilis.
ICD-9-CM Codes that Support Medical Necessity: The Fluorescent Treponemal Antibody Absorption test is determined to be medically necessary by
Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is
not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the
procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical
necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a
complete reference.
042
053.0 - 053.9
054.0 - 054.9
070.0 - 070.9
078.0
078.10 - 078.19
078.88
079.4
079.50 - 079.59
079.88
090.0 - 090.9
091.0 - 091.9
092.0 - 092.9
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
HERPES ZOSTER WITH MENINGITIS - HERPES ZOSTER
WITHOUT COMPLICATION
ECZEMA HERPETICUM - HERPES SIMPLEX WITHOUT
COMPLICATION
VIRAL HEPATITIS A WITH HEPATIC COMA - UNSPECIFIED
VIRAL HEPATITIS WITHOUT HEPATIC COMA
MOLLUSCUM CONTAGIOSUM
VIRAL WARTS UNSPECIFIED - OTHER SPECIFIED VIRAL
WARTS
OTHER SPECIFIED DISEASES DUE TO CHLAMYDIAE
HUMAN PAPILLOMAVIRUS IN CONDITIONS CLASSIFIED
ELSEWHERE AND OF UNSPECIFIED SITE
RETROVIRUS UNSPECIFIED - OTHER SPECIFIED
RETROVIRUS
OTHER SPECIFIED CHLAMYDIAL INFECTION
EARLY CONGENITAL SYPHILIS SYMPTOMATIC
CONGENITAL SYPHILIS UNSPECIFIED
GENITAL SYPHILIS (PRIMARY) - UNSPECIFIED
SECONDARY SYPHILIS
EARLY SYPHILIS LATENT SEROLOGICAL RELAPSE
AFTER TREATMENT - EARLY SYPHILIS LATENT UNSPECIFIED
093.0 - 093.9
094.0 - 094.9
095.0 - 095.9
096
097.0 - 097.9
098.0 - 098.89
099.0 - 099.9
104.0
131.00
131.02
131.03
131.09
131.8
131.9
290.10 - 290.13
ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC
CARDIOVASCULAR SYPHILIS UNSPECIFIED
TABES DORSALIS - NEUROSYPHILIS UNSPECIFIED
SYPHILITIC EPISCLERITIS - LATE SYMPTOMATIC SYPHILIS
UNSPECIFIED
LATE SYPHILIS LATENT
LATE SYPHILIS UNSPECIFIED - SYPHILIS UNSPECIFIED
GONOCOCCAL INFECTION (ACUTE) OF LOWER
GENITOURINARY TRACT - GONOCOCCAL INFECTION OF
OTHER SPECIFIED SITES
CHANCROID - VENEREAL DISEASE UNSPECIFIED
NONVENEREAL ENDEMIC SYPHILIS
UROGENITAL TRICHOMONIASIS UNSPECIFIED
TRICHOMONAL URETHRITIS
TRICHOMONAL PROSTATITIS
OTHER UROGENITAL TRICHOMONIASIS
TRICHOMONIASIS OF OTHER SPECIFIE
TRICHOMONIASIS UNSPECIFIED
PRESENILE DEMENTIA UNCOMPLICATED –
PRESENILE DEMENTIA WITH DEPRESSIVE
FEATURESD SITES
Last Updated:
12/5/13
Syphilis (L29416) 2 or 2
CPT Codes 86592, 86593 and 86780
LCD Description: The fluorescent treponemal antibody absorption (FTA-abs) test is the most widely employed treponemal test. It is a specific test for
the diagnosis of syphilis. The FTA-abs test includes a serum specimen which is absorbed and then tested with immunofluorescence for the antibody to
Treponema pallidum, the causative agent of syphilis.
FTA-abs is the most sensitive test in all stages of syphilis. The FTA-abs test is of value principally in determining whether a positive nontreponemal
antigen test (e.g., Rapid Plasma Reagin [RPR] or Venereal Disease Research Laboratory [VDRL]) is “false positive” or is indicative of syphilis. Because
of its great sensitivity, particularly in the late stages of the disease, the FTA-abs test is also of value when there is clinical evidence of syphilis but the
nontreponemal serologic test for syphilis is negative. The test is positive in most patients with primary syphilis and in virtually all with secondary syphilis.
ICD-9-CM Codes that Support Medical Necessity: The Fluorescent Treponemal Antibody Absorption test is determined to be medically necessary by
Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is
not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the
procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical
necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM book should be used as a
complete reference. 614.0 - 614.9 ACUTE SALPINGITIS AND OOPHORITIS - UNSPECIFIED
NFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS AND TISSUES
293.0
293.1
294.8
296.82
310.1
331.0
331.2
331.9
356.0
356.9
389.10
604.0
604.90
604.91
DELIRIUM DUE TO CONDITIONS
SUBACUTE DELIRIUM
OTHER PERSISTENT MENTAL DISORDERS DUE
TO CONDITIONS CLASSIFIED ELSEWHERE
ATYPICAL DEPRESSIVE DISORDER
PERSONALITY CHANGE DUE TO CONDITIONS
ALZHEIMER'S DISEASE
SENILE DEGENERATION OF BRAIN
CEREBRAL DEGENERATION UNSPECIFIED
HEREDITARY PERIPHERAL NEUROPATHY
UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY
SENSORINEURAL HEARING LOSS UNSPECIFIED
ORCHITIS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS
WITH ABSCESS
ORCHITIS AND EPIDIDYMITIS UNSPECIFIED
ORCHITIS AND EPIDIDYMITIS IN DISEASES CLASSIFIED
ELSEWHERE
614.0 - 614.9 ACUTE SALPINGITIS AND OOPHORITIS - UNSPECIFIED
NFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS AND TISSUES
615.0 - 615.9 ACUTE INFLAMMATORY DISEASES OF UTERUS EXCEPT
CERVIX - UNSPECIFIED INFLAMMATORY DISEASE OF UTERUS
616.0 - 616.9 CERVICITIS AND ENDOCERVICITIS - UNSPECIFIED
INFLAMMATORY DISEASE OF CERVIX VAGINA AND VULVA
760.2
MATERNAL INFECTIONS AFFECTING FETUS OR NEWBORN
781.2
ABNORMALITY OF GAIT
782.1
RASH AND OTHER NONSPECIFIC SKIN ERUPTION
785.6
ENLARGEMENT OF LYMPH NODES
V01.6
CONTACT WITH OR EXPOSURE TO VENEREAL DISEASES
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
Last Updated:
12/5/13
Total Calcium (L29292) 1 of 3
CPT Code 82310
LCD Description: Calcium is a predominantly extracellular cation. It is of great importance in blood coagulation; it gives firmness and rigidity to bones
and teeth; it is important in acid-base balance; it is essential for lactation; it is important in activating enzymes; it is essential for the function of nerves
and muscles, including the myocardium; and for maintaining the permeability of membranes. Over 98% of body’s calcium is found in the bones and
teeth. The serum calcium test is used to evaluate parathyroid function and calcium metabolism by directly measuring the total amount of calcium in the
blood. About 50% of blood calcium is ionized; the rest is protein bound (with albumin). The serum calcium level is a measurement of both. The normal
adult serum calcium level is between 8.5-10.5mg/dl.
ICD-9-CM Codes that Support Medical Necessity: The Total Calcium test is determined to be medically necessary by Medicare only when it is
test(s) provided.
135
140.0 - 208.92
209.00 - 209.03
209.10 - 209.17
209.20 - 209.29
209.30 - 209.36
252.00 - 252.08
252.1
255.41
255.42
260 - 269.9
275.41
275.42
SARCOIDOSIS
MALIGNANT NEOPLASM OF UPPER LIP VERMILION
BORDER - UNSPECIFIED LEUKEMIA, IN RELAPSE
MALIGNANT CARCINOID TUMOR OF THE SMALL INTESTINE,
UNSPECIFIED PORTION - MALIGNANT CARCINOID TUMOR OF THE ILEUM
MALIGNANT CARCINOID TUMOR OF THE LARGE INTESTINE,
UNSPECIFIED PORTION - MALIGNANT CARCINOID TUMOR OF THE
RECTUM
MALIGNANT CARCINOID TUMOR OF UNKNOWN PRIMARY
SITE - MALIGNANT CARCINOID TUMOR OF OTHER SITES
MALIGNANT POORLY DIFFERENTIATED NEUROENDOCRINE
CARCINOMA, ANY SITE - MERKEL CELL CARCINOMA OF OTHER SITES
HYPERPARATHYROIDISM, UNSPECIFIED - OTHER
HYPERPARATHYROIDISM
HYPOPARATHYROIDISM
GLUCOCORTICOID DEFICIENCY
MINERALOCORTICOID DEFICIENCY
KWASHIORKOR - UNSPECIFIED NUTRITIONAL DEFICIENCY
HYPOCALCEMIA
HYPERCALCEMIA
275.49
276.0 - 276.9
278.4
293.0
293.1
293.83
298.9
300.00 - 300.09
368.13
368.2
427.0 - 427.9
519.11
519.19
564.00 - 564.09
577.0
577.1
HYPEROSMOLALITY AND/OR HYPERNATREMIA
ELECTROLYTE AND FLUID DISORDERS NOT
ELSEWHERE CLASSIFIED
HYPERVITAMINOSIS D
DELIRIUM DUE TO CONDITIONS CLASSIFIED
ELSEWHERE
SUBACUTE DELIRIUM
MOOD DISORDER IN CONDITIONS CLASSIFIED
ELSEWHERE
ANXIETY STATE UNSPECIFIED - OTHER ANXIETY
STATES
VISUAL DISCOMFORT
DIPLOPIA
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
CARDIAC DYSRHYTHMIA UNSPECIFIED
ACUTE BRONCHOSPASM
OTHER DISEASES OF TRACHEA AND BRONCHUS
UNSPECIFIED CONSTIPATION - OTHER CONSTIPATION
ACUTE PANCREATITIS
CHRONIC PANCREATITIS
* According to the ICD-9-CM book, Diagnosis codes E934.2, E936.3, E943.3, E944.4, and E944.5 are secondary diagnosis codes and should not be billed as the
primary diagnosis.
Last Updated:
12/5/13
CPT Code 82310
test(s) provided.
579.0 - 579.9
580.0 - 580.9
581.0 - 581.9
582.0 - 582.9
583.0 - 583.9
584.5 - 584.9
585.1 - 585.9
586
587
588.0 - 588.9
592.0
728.87
728.88
728.89
728.9
ACUTE GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS
ACUTE GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
NEPHROTIC SYNDROME WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS –
NEPHROTIC SYNDROME WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
CHRONIC GLOMERULONEPHRITIS WITH LESION OF PROLIFERATIVE GLOMERULONEPHRITIS –
CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR CHRONIC WITH LESION OF
PROLIFERATIVE GLOMERULONEPHRITIS - NEPHRITIS AND NEPHROPATHY NOT SPECIFIED AS ACUTE OR
CHRONIC WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY
ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS - ACUTE KIDNEY FAILURE, UNSPECIFIED
CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC KIDNEY DISEASE, UNSPECIFIED
RENAL SCLEROSIS UNSPECIFIED
RENAL OSTEODYSTROPHY - UNSPECIFIED DISORDER RESULTING FROM IMPAIRED RENAL FUNCTION
CALCULUS OF KIDNEY
RHABDOMYOLYSIS
UNSPECIFIED DISORDER OF MUSCLE LIGAMENT AND FASCIA
primary diagnosis.
Last Updated:
12/5/13
CPT Code 82310
test(s) provided.
729.82
733.90
780.01
780.09
780.1
780.39
780.79
781.0
781.7
782.0
783.0
783.5
785.59
787.01 - 787.04
787.20 - 787.29
788.42
788.43
789.00
CRAMP OF LIMB
COMA
HALLUCINATIONS
OTHER CONVULSIONS
TETANY
DISTURBANCE OF SKIN SENSATION
ANOREXIA
POLYDIPSIA
OTHER SHOCK WITHOUT TRAUMA
POLYURIA
NOCTURIA
ABDOMINAL PAIN UNSPECIFIED SITE
E934.2*
E936.3*
E943.3*
E944.4*
E944.5*
ANTICOAGULANTS CAUSING ADVERSE EFFECTS
IN THERAPEUTIC USE
OTHER AND UNSPECIFIED ANTICONVULSANTS
OTHER CATHARTICS INCLUDING INTESTINAL ATONIA
DRUGS CAUSING ADVERSE EFFECTS IN THERAPEUTIC USE
OTHER DIURETICS CAUSING ADVERSE EFFECTS IN
THERAPEUTIC USE
ELECTOLYTIC CALORIC AND WATER-BALANCE AGENTS
primary diagnosis.
Last Updated:
12/5/13
Vitamin D; 25 Hydroxy, includes Fraction(s) if performed (L30868)
CPT Code 82306
LCD Description:
Vitamin D, a group of fat-soluble prohormones, is an essential vitamin. There are two major types of Vitamin D (Vitamin D2 and Vitamin D3)
which are collectively known as calciferol. They are essential for promoting calcium absorption and maintaining adequate serum calcium and
phosphate concentrations to enable mineralization of bone and prevent hypocalcemic conditions. Vitamin D2 (ergocalciferol) is obtained from
foods of plant origin and vitamin D3 (cholecalciferol) is obtained from foods of animal origin and ultraviolet light-stimulated conversion of 7dehydrocholestral in the skin. Vitamin D is stored in the human body as calcidiol (25-hydroxyvitamin D). Serum concentration of 25(OH) D is
the best indicator of vitamin D status.
Vitamin D deficiencies are the result of dietary inadequacy, impaired absorption and use, increased requirement, or increased excretion.
Vitamin D deficiency can occur when usual intake is lower than recommended levels over a period of time, or when exposure to sunlight is
limited. Vitamin D deficiency can also result from the inability of the kidneys to convert the vitamin D to its active form. Vitamin D toxicity can
cause symptoms including nausea, vomiting, poor appetite, constipation, weakness, and weight loss as well as elevation in the blood level of
calcium which in turn can lead to mental status changes, and heart rhythm abnormalities.
ICD-9-CM Codes that Support Medical Necessity: The Vitamin D test is determined to be medically necessary by Medicare only when it
is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough
to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the
procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support
the medical necessity for the test(s). This list was compiled from the Medicare National Coverage Determination Policy. An ICD-D-9-CM
book should be used as a complete reference.
252.00
252.01
252.02
252.08
252.1
268.0
268.2
268.9
275.3
275.41
275.42
278.4
571.2
571.5
HYPERPARATHYROIDISM, UNSPECIFIED
PRIMARY HYPERPARATHYROIDISM
SECONDARY HYPERPARATHYROIDISM, NON-RENAL
OTHER HYPERPARATHYROIDISM
HYPOPARATHYROIDISM
RICKETS ACTIVE
OSTEOMALACIA UNSPECIFIED
UNSPECIFIED VITAMIN D DEFICIENCY
HYPOCALCEMIA
HYPERCALCEMIA
HYPERVITAMINOSIS D
ALCOHOLIC CIRRHOSIS OF LIVER
CIRRHOSIS OF LIVER WITHOUT ALCOHOL
571.6
579.0 - 579.9
585.3
585.4
585.5
585.6
588.81
733.00
733.01
733.02
733.03
733.09
733.90
BILIARY CIRRHOSIS
CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)
OSTEOPOROSIS UNSPECIFIED
SENILE OSTEOPOROSIS
IDIOPATHIC OSTEOPOROSIS
DISUSE OSTEOPOROSIS
OTHER OSTEOPOROSIS
Last Updated:
12/5/13

Medicare National and Local Coverage Determination Policy – FLORIDA

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