Medicare National and Local Coverage Determination Policy – Texas

Transcription

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

Medicare National and Local Coverage Determination Policy – Texas

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