Medicare National and Local Coverage Determination Policy – DE, MD,...

Medicare National and Local Coverage Determination Policy – DE, MD, NJ, PA
Policies in this MLCP Reference Guide apply to testing performed at a Quest Diagnostics facility and apply to Medicare National Coverage Determination Policy.
This diagnosis code reference guide is provided as an aid to physicians and office staff in determining when an ABN (Advance Beneficiary Notice) is necessary.
Diagnosis codes must be applicable to the patient’s symptoms or conditions and must be consistent with documentation in the patient’s medical record.
Quest Diagnostics does not recommend any diagnosis codes and will only submit diagnosis information provided to us by the ordering physician or his/her
designated staff. The CPT codes provided are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the
billing party. Please direct any questions regarding coding to the payer being billed.
Please note this document has been updated with National Medicare changes effective 4/1/2012
• Click here for National MLCP Policies Tool
Document contains information on National Medicare
Limited Coverage Policies
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Alpha-Fetoprotein
Blood Counts
Blood Glucose Testing
Carcinoembryonic Antigen
Collagen Crosslinks - Any Method
Digoxin Therapeutic Drug Assay
Fecal Occult Blood
Gamma Glutamyl Transferase
Glycated Hemoglobin - Glycated Protein
Hepatitis Panel/Acute Hepatitis Panel
Human Chorionic Gonadotropin
Human Immunodeficiency Virus (HIV) Testing
(Diagnosis)
Human Immunodeficiency Virus (HIV) Testing
(Prognosis Including Monitoring)
Lipids Testing
Partial Thromboplastin Time (PTT)
Prostate Specific Antigen
Prothrombin Time (PT)
Serum Iron Studies
Thyroid Testing
Tumor Antigen by Immunoassay CA 15-3 CA 27.29
Tumor Antigen by Immunoassay CA 19-9
Tumor Antigen by Immunoassay CA-125
Urine Culture, Bacterial
• Click policy below for Local MLCP Policy Tool
Document contains the below Medicare Local
Limited Coverage Policies for lab testing performed in
DE, DC, MD, NJ, PA.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
B-type Natriuretic Peptide (BNP) Assays
C-Reactive Protein Testing
Cyanocobalamin (Vitamin B-12)
Cytogenetic Analysis Testing
Debridement of Mycotic Nails
Flow Cytometry
Flow Cytometry:Cell Cycle or DNA Analysis
ImmunoCAP(R) Radioallergosorbent Test,
Fluoroallergosorbent Testing
Moh’s Micrographic Surgery
Molecular Diagnostics: Genitourinary Infectious
Disease
Molecular Diagnostics: Human Papillomavirus
Molecular Diagnostics: Not otherwise specified
OVA-1 Assay
Parathormone (Parathyroid Hormone)
Qaulitative Drug Testing
Vitamin D: 25 Hydroxy
Vitamin D: 1,25 Dihydroxy
QuestDiagnostics.com
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Last Updated:
1/01/12
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
B-type Natriuretic Peptide (BNP) Assays (1 of 2)
CPT Code: 83880
Data Source: https://www.novitas-solutions.com
LCD Description: B-type natriuretic peptide (BNP), a naturally occurring hormone, is secreted primarily in response to pressure and volume overload in the heart. BNP
measurements may be considered reasonable and necessary when used in combination with other clinical data such as medical history, physical examination,
laboratory studies, chest x-ray, and electrocardiography.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
402.01
402.11
402.91
404.01
404.03
404.11
MALIGNANT HYPERTENSIVE HEART DISEASE
WITH HEART FAILURE
BENIGN HYPERTENSIVE HEART DISEASE WITH
HEART FAILURE
UNSPECIFIED HYPERTENSIVE HEART DISEASE
WITH HEART FAILURE
HYPERTENSIVE HEART AND CHRONIC KIDNEY
DISEASE, MALIGNANT, WITH HEART FAILURE
AND WITH CHRONIC KIDNEY DISEASE STAGE I
THROUGH STAGE IV, OR UNSPECIFIED
HYPERTENSIVE HEART AND CHRONIC KIDNEY
DISEASE, MALIGNANT, WITH HEART FAILURE
AND WITH CHRONIC KIDNEY DISEASE STAGE V
OR END STAGE RENAL DISEASE
HYPERTENSIVE HEART AND CHRONIC KIDNEY
DISEASE, BENIGN, WITH HEART FAILURE AND
WITH CHRONIC KIDNEY DISEASE STAGE I
THROUGH STAGE IV, OR UNSPECIFIED
404.13
HYPERTENSIVE HEART AND CHRONIC KIDNEY
DISEASE, BENIGN, WITH HEART FAILURE AND
CHRONIC KIDNEY DISEASE STAGE V OR END
STAGE RENAL DISEASE
404.91
HYPERTENSIVE HEART AND CHRONIC KIDNEY
DISEASE, UNSPECIFIED, WITH HEART FAILURE
AND WITH CHRONIC KIDNEY DISEASE STAGE I
THROUGH STAGE IV, OR UNSPECIFIED
404.93
HYPERTENSIVE HEART AND CHRONIC KIDNEY
DISEASE, UNSPECIFIED, WITH HEART FAILURE AND
CHRONIC KIDNEY DISEASE STAGE V OR END
STAGE RENAL DISEASE
410.00 – 410.92ACUTE MYOCARDIAL INFARCTION OF A
NTEROLATERAL WALL EPISODE OF CARE
UNSPECIFIED - ACUTE MYOCARDIAL I NFARCTION
OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF
CARE
411.1
INTERMEDIATE CORONARY SYNDROME
415.0
ACUTE COR PULMONALE
416.0
PRIMARY PULMONARY HYPERTENSION
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
B-type Natriuretic Peptide (BNP) Assays (2 of 2)
CPT Code: 83880
Data Source: https://www.novitas-solutions.com
LCD Description: B-type natriuretic peptide (BNP), a naturally occurring hormone, is secreted primarily in response to pressure and volume overload in the heart. BNP
measurements may be considered reasonable and necessary when used in combination with other clinical data such as medical history, physical examination,
laboratory studies, chest x-ray, and electrocardiography.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
423.2
425.11
CONSTRICTIVE PERICARDITIS
HYPERTROPHIC OBSTRUCTIVE
CARDIOMYOPATHY
425.18
OTHER HYPERTROPHIC CARDIOMYOPATHY
425.4
OTHER PRIMARY CARDIOMYOPATHIES
428.0 - 428.1 CONGESTIVE HEART FAILURE UNSPECIFIED –
LEFT HEART FAILURE
428.20 - 428.23 UNSPECIFIED SYSTOLIC HEART
FAILURE - ACUTE ON CHRONIC SYSTOLIC HEART
FAILURE
428.30 - 428.33 UNSPECIFIED DIASTOLIC HEART FAILURE ACUTE ON CHRONIC DIASTOLIC HEART FAILURE
428.40 - 428.43 UNSPECIFIED COMBINED SYSTOLIC AND
DIASTOLIC HEART FAILURE - ACUTE ON
CHRONIC COMBINED SYSTOLIC AND DIASTOLIC
HEART FAILURE
428.9
HEART FAILURE UNSPECIFIED
493.01 - 493.02 EXTRINSIC ASTHMA WITH STATUS
ASTHMATICUS - EXTRINSIC ASTHMA WITH
(ACUTE) EXACERBATION
493.11 - 493.12 INTRINSIC ASTHMA WITH STATUS ASTHMATICUS
- INTRINSIC ASTHMA WITH (ACUTE)
ACERBATION
493.21 - 493.22 CHRONIC OBSTRUCTIVE ASTHMA WITH STATUS
ASTHMATICUS - CHRONIC OBSTRUCTIVE
ASTHMA WITH (ACUTE) EXACERBATION
493.81 - 493.82 EXERCISE-INDUCED BRONCHOSPASM - COUGH
VARIANT ASTHMA
493.91 - 493.92 ASTHMA UNSPECIFIED TYPE WITH STATUS
ASTHMATICUS - ASTHMA UNSPECIFIED WITH
(ACUTE) EXACERBATION
782.3
EDEMA
786.00
RESPIRATORY ABNORMALITY UNSPECIFIED
786.02
ORTHOPNEA
786.05
SHORTNESS OF BREATH
786.06
TACHYPNEA
786.07
WHEEZING
786.09
RESPIRATORY ABNORMALITY OTHER
786.7
ABNORMAL CHEST SOUNDS
Utilization Guidelines
As a diagnostic test, BNP testing is not expected to be performed more
than four times in a 12 month period in the non-facility setting.
The use of BNP for monitoring CHF is not covered.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
C-Reactive Protein Testing
CPT Code: 86141
Data Source: https://www.novitas-solutions.com
LCD Description: C-Reactive Protein, (CRP), is a nonspecific, acute-phase reactant produced in response to tissue injury, inflammation or infection. As an acute phase
reactant, concentrations rise rapidly and half-life is short. Recent studies have shown that chronic, low-grade inflammation contributes to atherogenesis and the
development of coronary artery disease (CAD). Inflammatory changes lead to progressive disease, which culminates in plaque instability, rupture, thrombosis, and
myocardial infarction (MI).
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
272.0
272.1
272.2
272.3
272.4
414.01
V49.89*
PURE HYPERCHOLESTEROLEMIA
PURE HYPERGLYCERIDEMIA
MIXED HYPERLIPIDEMIA
HYPERCHYLOMICRONEMIA
OTHER AND UNSPECIFIED HYPERLIPIDEMIA
CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY
OTHER SPECIFIED CONDITIONS INFLUENCING HEALTH STATUS
Note: per Novitas Medicare LCD policy
*Use ICD-9-CM code V49.89 for patients at intermediate risk for CAD who do not have elevated lipids (i.e., do not meet criteria to use ICD-9-CM
codes 272.0-272.4)
Utilization Guidelines
Generally, the measurement of hsCRP markers is performed twice (averaging results), optimally two weeks apart and fasting or nonfasting, with
the average expressed in mg/L, in metabolically stable patients.
If an average CRP level of >10.0 mg/L is found on two tests performed 2 weeks apart, a third test may be performed after ruling out possible
infectious or inflammatory causes for the increase (AHA/CDC Recommendation).
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
CYANOCOBALAMIN (VITAMIN B-12) (1 of 3)
CPT Code: 82607
Data Source: https://www.novitas-solutions.com
LCD Description: The serum cyanocobalamin is a quantitative analysis of serum Vitamin B12 levels. It is generally indicated in the evaluation of macrocytic anemias
whose cause is unknown, and in patients with malabsorptive states. Vitamin B12 (and / or folate) deficiency may be present when one or more of the following findings
are present: oval macrocytic red blood cells on peripheral blood smear, with or without anemia; hypersegmented neutrophils on peripheral blood smear; pancytopenia
of uncertain cause (anemia, thrombocytopenia, and neutropenia), unexplained neurologic signs and symptoms: especially dementia, weakness, sensory ataxia,
paresthesias (e.g., suspected subacute combined degeneration), or increased risk for deficiency due to alcoholism, malnutrition, strict vegan diet, malabsorption,
certain medications.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
040.2
123.4
151.0 - 151.9
152.0 - 152.9
157.0 - 157.9
197.4
197.8
261
262
263.0
263.2
263.8 - 263.9
WHIPPLE'S DISEASE
DIPHYLLOBOTHRIASIS INTESTINAL
MALIGNANT NEOPLASM OF CARDIA - MALIGNANT
NEOPLASM OF STOMACH UNSPECIFIED SITE
MALIGNANT NEOPLASM OF DUODENUM - MALIGNANT
NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE
MALIGNANT NEOPLASM OF HEAD OF PANCREAS MALIGNANT NEOPLASM OF PANCREAS PART
UNSPECIFIED
SECONDARY MALIGNANT NEOPLASM OF SMALL
INTESTINE INCLUDING DUODENUM
SECONDARY MALIGNANT NEOPLASM OF OTHER
DIGESTIVE ORGANS AND SPLEEN
NUTRITIONAL MARASMUS
OTHER SEVERE PROTEIN-CALORIE MALNUTRITION
MALNUTRITION OF MODERATE DEGREE
ARRESTED DEVELOPMENT FOLLOWING PROTEINCALORIE MALNUTRITION
OTHER PROTEIN-CALORIE MALNUTRITION UNSPECIFIED PROTEIN-CALORIE MALNUTRITION
266.2
270.4
281.0 - 281.3
281.9
284.11
284.12
284.19
285.21
285.9
290.0
290.10
290.41
290.42
290.43
OTHER B-COMPLEX DEFICIENCIES
DISTURBANCES OF SULPHUR-BEARING
AMINO-ACID METABOLISM
PERNICIOUS ANEMIA - OTHER SPECIFIED
MEGALOBLASTIC ANEMIAS NOT
ELSEWHERE CLASSIFIED
UNSPECIFIED DEFICIENCY ANEMIA
ANTINEOPLASTIC CHEMOTHERAPY INDUCED
PANCYTOPENIA
OTHER DRUG INDUCED PANCYTOPENIA
OTHER PANCYTOPENIA
ANEMIA IN CHRONIC KIDNEY DISEASE
ANEMIA UNSPECIFIED
SENILE DEMENTIA UNCOMPLICATED
PRESENILE DEMENTIA UNCOMPLICATED
VASCULAR DEMENTIA, WITH DELIRIUM
VASCULAR DEMENTIA, WITH DELUSIONS
VASCULAR DEMENTIA, WITH DEPRESSED
MOOD
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
CYANOCOBALAMIN (VITAMIN B-12) (2 of 3)
CPT Code: 82607
Data Source: https://www.novitas-solutions.com
LCD Description: The serum cyanocobalamin is a quantitative analysis of serum Vitamin B12 levels. It is generally indicated in the evaluation of macrocytic anemias
whose cause is unknown, and in patients with malabsorptive states. Vitamin B12 (and / or folate) deficiency may be present when one or more of the following findings
are present: oval macrocytic red blood cells on peripheral blood smear, with or without anemia; hypersegmented neutrophils on peripheral blood smear; pancytopenia
of uncertain cause (anemia, thrombocytopenia, and neutropenia), unexplained neurologic signs and symptoms: especially dementia, weakness, sensory ataxia,
paresthesias (e.g., suspected subacute combined degeneration), or increased risk for deficiency due to alcoholism, malnutrition, strict vegan diet, malabsorption,
certain medications.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
291.1
291.2
293.0
294.10
294.11
294.20
294.21
294.8
303.91
331.6
ALCOHOL-INDUCED PERSISTING AMNESTIC
DISORDER
ALCOHOL-INDUCED PERSISTING DEMENTIA
DELIRIUM DUE TO CONDITIONS CLASSIFIED
ELSEWHERE
DEMENTIA IN CONDITIONS CLASSIFIED
ELSEWHERE WITHOUT BEHAVIORAL
DISTURBANCE
DEMENTIA IN CONDITIONS CLASSIFIED
ELSEWHERE WITH BEHAVIORAL
DISTURBANCE
DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL
DISTURBANCE
DEMENTIA, UNSPECIFIED, WITH BEHAVIORAL
DISTURBANCE
OTHER PERSISTENT MENTAL DISORDERS DUE TO
CONDITIONS CLASSIFIED ELSEWHERE
OTHER AND UNSPECIFIED ALCOHOL DEPENDENCE
CONTINUOUS DRINKING BEHAVIOR
CORTICOBASAL DEGENERATION
331.7
331.83
334.4
354.8 - 354.9
355.8 - 355.9
356.4
356.9
377.33
377.34
529.0
529.4
529.6
CEREBRAL DEGENERATION IN DISEASES
CLASSIFIED ELSEWHERE
MILD COGNITIVE IMPAIRMENT, SO STATED
CEREBELLAR ATAXIA IN DISEASES
CLASSIFIED ELSEWHERE
OTHER MONONEURITIS OF UPPER LIMB MONONEURITIS OF UPPER LIMB
UNSPECIFIED
MONONEURITIS OF LOWER LIMB
UNSPECIFIED - MONONEURITIS OF
UNSPECIFIED SITE
IDIOPATHIC PROGRESSIVE
POLYNEUROPATHY
UNSPECIFIED IDIOPATHIC PERIPHERAL
NEUROPATHY
NUTRITIONAL OPTIC NEUROPATHY
TOXIC OPTIC NEUROPATHY
GLOSSITIS
ATROPHY OF TONGUE PAPILLAE
GLOSSODYNIA
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
CYANOCOBALAMIN (VITAMIN B-12) (3 of 3)
CPT Code: 82607
Data Source: https://www.novitas-solutions.com
LCD Description: The serum cyanocobalamin is a quantitative analysis of serum Vitamin B12 levels. It is generally indicated in the evaluation of macrocytic anemias
whose cause is unknown, and in patients with malabsorptive states. Vitamin B12 (and / or folate) deficiency may be present when one or more of the following findings
are present: oval macrocytic red blood cells on peripheral blood smear, with or without anemia; hypersegmented neutrophils on peripheral blood smear; pancytopenia
of uncertain cause (anemia, thrombocytopenia, and neutropenia), unexplained neurologic signs and symptoms: especially dementia, weakness, sensory ataxia,
paresthesias (e.g., suspected subacute combined degeneration), or increased risk for deficiency due to alcoholism, malnutrition, strict vegan diet, malabsorption,
certain medications.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
535.10 - 535.11 ATROPHIC GASTRITIS (WITHOUT
HEMORRHAGE) - ATROPHIC GASTRITIS WITH
HEMORRHAGE
536.0
ACHLORHYDRIA
555.0 - 555.9 REGIONAL ENTERITIS OF SMALL
INTESTINE - REGIONAL ENTERITIS OF
UNSPECIFIED SITE
564.2
POSTGASTRIC SURGERY SYNDROMES
577.1
CHRONIC PANCREATITIS
579.0 - 579.9 CELIAC DISEASE - UNSPECIFIED
INTESTINAL MALABSORPTION
751.1
CONGENITAL ATRESIA AND STENOSIS OF SMALL
INTESTINE
780.93
MEMORY LOSS
780.97
ALTERED MENTAL STATUS
781.2
ABNORMALITY OF GAIT
781.3
LACK OF COORDINATION
782.0
DISTURBANCE OF SKIN SENSATION
V10.00
PERSONAL HISTORY OF MALIGNANT NEOPLASM OF
UNSPECIFIED SITE IN GASTROINTESTINAL TRACT
V10.04
V10.09
V12.1
V44.1
V44.2
V44.4
V45.3
V45.72
V45.75
V45.86
V58.69
PERSONAL HISTORY OF MALIGNANT
NEOPLASM OF STOMACH
PERSONAL HISTORY OF MALIGNANT
NEOPLASM OF OTHER SITES IN
GASTROINTESTINAL TRACT
PERSONAL HISTORY OF NUTRITIONAL
DEFICIENCY
GASTROSTOMY STATUS
ILEOSTOMY STATUS
STATUS OF OTHER ARTIFICIAL OPENING
OF GASTROINTESTINAL TRACT
POSTSURGICAL INTESTINAL BYPASS OR
ANASTOMOSIS
STATUS
ACQUIRED ABSENCE OF INTESTINE
(LARGE) (SMALL)
ACQUIRED ABSENCE OF ORGAN STOMACH
BARIATRIC SURGERY STATUS
LONG-TERM (CURRENT) USE OF OTHER
MEDICATIONS
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Data Source: https://www.novitas-solutions.com
Cytogenetic Analysis Testing (Page 1 of 7)
CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249,
88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285,
88289, 88291, 88299, 88365, 88367, 88368
LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques, and
molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to confirm
number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
140.0 - 140.9
141.0 - 141.9
142.0 - 142.9
143.0 - 143.9
150.0 - 150.9
151.0 - 151.9
152.1 - 152.8
158.0
162.0 - 165.9
MALIGNANT NEOPLASM OF UPPER LIP VERMILION
BORDER - MALIGNANT NEOPLASM OF LIP
UNSPECIFIED VERMILION BORDER
MALIGNANT NEOPLASM OF BASE OF TONGUE MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED
MALIGNANT NEOPLASM OF PAROTID GLAND MALIGNANT NEOPLASM OF SALIVARY GLAND
UNSPECIFIED
MALIGNANT NEOPLASM OF UPPER GUM MALIGNANT NEOPLASM OF GUM UNSPECIFIED
MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS
- MALIGNANT NEOPLASM OF ESOPHAGUS
UNSPECIFIED SITE
MALIGNANT NEOPLASM OF CARDIA - MALIGNANT
NEOPLASM OF STOMACH UNSPECIFIED SITE
MALIGNANT NEOPLASM OF JEJUNUM - MALIGNANT
NEOPLASM OF OTHER SPECIFIED SITES OF SMALL
INTESTINE
MALIGNANT NEOPLASM OF RETROPERITONEUM
MALIGNANT NEOPLASM OF TRACHEA - MALIGNANT
NEOPLASM OF ILL-DEFINED SITES WITHIN THE
RESPIRATORY SYSTEM
170.0 - 170.9
MALIGNANT NEOPLASM OF BONES OF SKULL
AND FACE EXCEPT MANDIBLE - MALIGNANT
NEOPLASM OF BONE AND ARTICULAR
CARTILAGE SITE UNSPECIFIED
171.0 - 171.9 MALIGNANT NEOPLASM OF CONNECTIVE AND
OTHER SOFT TISSUE OF HEAD FACE AND NECK
- MALIGNANT NEOPLASM OF CONNECTIVE AND
OTHER SOFT TISSUE SITE UNSPECIFIED
173.00 - 173.99 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN
OF LIP - OTHER SPECIFIED MALIGNANT
NEOPLASM OF SKIN, SITE UNSPECIFIED
174.0 - 174.9 MALIGNANT NEOPLASM OF NIPPLE AND
AREOLA OF FEMALE BREAST - MALIGNANT
NEOPLASM OF BREAST (FEMALE) UNSPECIFIED
SITE
175.0 - 175.9 MALIGNANT NEOPLASM OF NIPPLE AND
AREOLA OF MALE BREAST - MALIGNANT
NEOPLASM OF OTHER AND UNSPECIFIED SITES
OF MALE BREAST
183.0
MALIGNANT NEOPLASM OF OVARY
183.2
MALIGNANT NEOPLASM OF FALLOPIAN TUBE
183.3
MALIGNANT NEOPLASM OF BROAD LIGAMENT
OF UTERUS
183.4
MALIGNANT NEOPLASM OF PARAMETRIUM
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Data Source: https://www.novitas-solutions.com
Cytogenetic Analysis Testing (Page 2 of 7)
CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249,
88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285,
88289, 88291, 88299, 88365, 88367, 88368
LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques,
and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to
confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
183.5
183.8
183.9
188.0 - 188.9
189.0 - 189.9
190.1
191.0 - 191.9
192.3
194.0 - 194.9
197.0 - 197.8
MALIGNANT NEOPLASM OF ROUND LIGAMENT OF
UTERUS
MALIGNANT NEOPLASM OF OTHER SPECIFIED
SITES OF UTERINE ADNEXA
MALIGNANT NEOPLASM OF UTERINE ADNEXA
UNSPECIFIED SITE
MALIGNANT NEOPLASM OF TRIGONE OF URINARY
BLADDER - MALIGNANT NEOPLASM OF BLADDER
PART UNSPECIFIED
MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS
- MALIGNANT NEOPLASM OF URINARY ORGAN SITE
UNSPECIFIED
MALIGNANT NEOPLASM OF ORBIT
MALIGNANT NEOPLASM OF CEREBRUM EXCEPT
LOBES AND VENTRICLES - MALIGNANT NEOPLASM
OF BRAIN UNSPECIFIED SITE
MALIGNANT NEOPLASM OF SPINAL MENINGES
MALIGNANT NEOPLASM OF ADRENAL GLAND MALIGNANT NEOPLASM OF ENDOCRINE GLAND SITE
UNSPECIFIED
SECONDARY MALIGNANT NEOPLASM OF LUNG SECONDARY MALIGNANT NEOPLASM OF OTHER
DIGESTIVE ORGANS AND SPLEEN
198.0 - 198.89 SECONDARY MALIGNANT NEOPLASM OF
KIDNEY - SECONDARY MALIGNANT NEOPLASM
OF OTHER SPECIFIED SITES
200.00 - 202.98 RETICULOSARCOMA UNSPECIFIED SITE OTHER AND UNSPECIFIED MALIGNANT
NEOPLASMS OF LYMPHOID AND HISTIOCYTIC
TISSUE INVOLVING LYMPH NODES OF
MULTIPLE SITES
203.00 - 203.02 MULTIPLE MYELOMA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION - MULTIPLE
MYELOMA, IN RELAPSE
203.10 - 203.12 PLASMA CELL LEUKEMIA, WITHOUT MENTION
OF HAVING ACHIEVED REMISSION - PLASMA
CELL LEUKEMIA, IN RELAPSE
203.80 - 203.82 OTHER IMMUNOPROLIFERATIVE NEOPLASMS,
WITHOUT MENTION OF HAVING ACHIEVED
REMISSION - OTHER IMMUNOPROLIFERATIVE
NEOPLASMS, IN RELAPSE
204.00 - 204.02 ACUTE LYMPHOID LEUKEMIA, WITHOUT
MENTION OF HAVING ACHIEVED REMISSION ACUTE LYMPHOID LEUKEMIA, IN RELAPSE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Data Source: https://www.novitas-solutions.com
Cytogenetic Analysis Testing (Page 3 of 7)
CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249,
88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285,
88289, 88291, 88299, 88365, 88367, 88368
LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques,
and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to
confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
204.10 - 204.12 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION
OF HAVING ACHIEVED REMISSION - CHRONIC
LYMPHOID LEUKEMIA, IN RELAPSE
204.20 - 204.22 SUBACUTE LYMPHOID LEUKEMIA, WITHOUT
MENTION OF HAVING ACHIEVED REMISSION SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE
204.80 - 204.82 OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION
OF HAVING ACHIEVED REMISSION - OTHER
LYMPHOID LEUKEMIA, IN RELAPSE
204.90 - 204.92 UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT
MENTION OF HAVING ACHIEVED REMISSION UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE
205.00 - 205.92 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION - UNSPECIFIED
MYELOID LEUKEMIA, IN RELAPSE
206.00 - 206.92 ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION
OF HAVING ACHIEVED REMISSION - UNSPECIFIED
MONOCYTIC LEUKEMIA, IN RELAPSE
207.00 - 207.82 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA,
WITHOUT MENTION OF HAVING ACHIEVED
REMISSION - OTHER SPECIFIED LEUKEMIA, IN
RELAPSE
208.00 - 208.02 ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE,
WITHOUT MENTION OF HAVING ACHIEVED
REMISSION - ACUTE LEUKEMIA OF
UNSPECIFIED CELL TYPE, IN RELAPSE
208.10 - 208.12 CHRONIC LEUKEMIA OF UNSPECIFIED CELL
TYPE, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - CHRONIC LEUKEMIA OF
UNSPECIFIED CELL TYPE, IN RELAPSE
208.20 - 208.22 SUBACUTE LEUKEMIA OF UNSPECIFIED CELL
TYPE, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - SUBACUTE LEUKEMIA
OF UNSPECIFIED CELL TYPE, IN RELAPSE
208.80 - 208.82 OTHER LEUKEMIA OF UNSPECIFIED CELL
TYPE, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - OTHER LEUKEMIA OF
UNSPECIFIED CELL TYPE, IN RELAPSE
208.90 - 208.92 UNSPECIFIED LEUKEMIA, WITHOUT MENTION
OF HAVING ACHIEVED REMISSION UNSPECIFIED LEUKEMIA, IN RELAPSE
223.3
BENIGN NEOPLASM OF BLADDER
225.2
BENIGN NEOPLASM OF CEREBRAL MENINGES
228.1
LYMPHANGIOMA ANY SITE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Data Source: https://www.novitas-solutions.com
Cytogenetic Analysis Testing (Page 4 of 7)
CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249,
88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285,
88289, 88291, 88299, 88365, 88367, 88368
LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques,
and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to
confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
230.0
CARCINOMA IN SITU OF LIP ORAL CAVITY AND
PHARYNX
231.0
CARCINOMA IN SITU OF LARYNX
232.9
CARCINOMA IN SITU OF SKIN SITE UNSPECIFIED
233.0
CARCINOMA IN SITU OF BREAST
233.30 - 233.39 CARCINOMA IN SITU, UNSPECIFIED FEMALE
GENITAL ORGAN - CARCINOMA IN SITU, OTHER
FEMALE GENITAL ORGAN
233.7
CARCINOMA IN SITU OF BLADDER
233.9
CARCINOMA IN SITU OF OTHER AND UNSPECIFIED
URINARY ORGANS
234.0
CARCINOMA IN SITU OF EYE
236.7
NEOPLASM OF UNCERTAIN BEHAVIOR OF BLADDER
238.4
POLYCYTHEMIA VERA
238.5
NEOPLASM OF UNCERTAIN BEHAVIOR OF
HISTIOCYTIC AND MAST CELLS
238.6
NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA
CELLS
238.71 - 238.79 ESSENTIAL THROMBOCYTHEMIA - OTHER
LYMPHATIC AND HEMATOPOIETIC TISSUES
239.2
NEOPLASM OF UNSPECIFIED NATURE OF BONE
SOFT TISSUE AND SKIN
239.3
NEOPLASM OF UNSPECIFIED NATURE OF BREAST
256.39
257.8
259.0
OTHER OVARIAN FAILURE
OTHER TESTICULAR DYSFUNCTION
DELAY IN SEXUAL DEVELOPMENT AND
PUBERTY NOT ELSEWHERE CLASSIFIED
273.1
MONOCLONAL PARAPROTEINEMIA
273.3
MACROGLOBULINEMIA
279.11
DIGEORGE'S SYNDROME
284.01 - 284.9 CONSTITUTIONAL RED BLOOD CELL APLASIA APLASTIC ANEMIA UNSPECIFIED
285.0
SIDEROBLASTIC ANEMIA
285.1
ACUTE POSTHEMORRHAGIC ANEMIA
285.21 - 285.29 ANEMIA IN CHRONIC KIDNEY DISEASE - ANEMIA
OF OTHER CHRONIC DISEASE
285.8
OTHER SPECIFIED ANEMIAS
285.9
ANEMIA UNSPECIFIED
287.30 - 287.39 PRIMARY THROMBOCYTOPENIA,UNSPECIFIED OTHER PRIMARY THROMBOCYTOPENIA
287.49
OTHER SECONDARY THROMBOCYTOPENIA
288.01*
CONGENITAL NEUTROPENIA
288.02
CYCLIC NEUTROPENIA
288.09
OTHER NEUTROPENIA
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Data Source: https://www.novitas-solutions.com
Cytogenetic Analysis Testing (Page 5 of 7)
CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249,
88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285,
88289, 88291, 88299, 88365, 88367, 88368
LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques,
and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to
confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
288.1 - 288.4
FUNCTIONAL DISORDERS OF
POLYMORPHONUCLEAR NEUTROPHILS HEMOPHAGOCYTIC SYNDROMES
288.59
OTHER DECREASED WHITE BLOOD CELL COUNT
288.63
MONOCYTOSIS (SYMPTOMATIC)
288.64
PLASMACYTOSIS
288.65
BASOPHILIA
288.69
OTHER ELEVATED WHITE BLOOD CELL COUNT
288.8
OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS
289.6
FAMILIAL POLYCYTHEMIA
289.7
METHEMOGLOBINEMIA
289.81 - 289.83 PRIMARY HYPERCOAGULABLE STATE –
MYELOFIBROSIS
289.89
OTHER SPECIFIED DISEASES OF BLOOD AND
BLOOD-FORMING ORGANS
299.00 - 299.11 AUTISTIC DISORDER, CURRENT OR ACTIVE STATE CHILDHOOD DISINTEGRATIVE DISORDER, RESIDUAL
STATE
317 - 319
MILD INTELLECTUAL DISABILITIES - UNSPECIFIED
INTELLECTUAL DISABILITIES
334.8
OTHER SPINOCEREBELLAR DISEASES
388.5
DISORDERS OF ACOUSTIC NERVE
389.10
SENSORINEURAL HEARING LOSS UNSPECIFIED
599.70 - 599.72 HEMATURIA, UNSPECIFIED - MICROSCOPIC
HEMATURIA
606.0
AZOOSPERMIA
606.1
OLIGOSPERMIA
611.1
HYPERTROPHY OF BREAST
628.9
INFERTILITY FEMALE OF UNSPECIFIED ORIGIN
629.9
UNSPECIFIED DISORDER OF FEMALE GENITAL
ORGANS
630
HYDATIDIFORM MOLE
631.0
INAPPROPRIATE CHANGE IN QUANTITATIVE
HUMAN CHORIONIC GONADOTROPIN (HCG) IN
EARLY PREGNANCY
631.8
OTHER ABNORMAL PRODUCTS OF
CONCEPTION
632
MISSED ABORTION
634.00 - 634.92 SPONTANEOUS ABORTION UNSPECIFIED
COMPLICATED BY GENITAL TRACT AND PELVIC
INFECTION - SPONTANEOUS ABORTION
COMPLETE WITHOUT COMPLICATION
646.33
RECURRENT PREGNANCY LOSS, ANTEPARTUM
CONDITION OR COMPLICATION
653.70
OTHER FETAL ABNORMALITY CAUSING
DISPROPORTION UNSPECIFIED AS TO EPISODE
OF CARE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Data Source: https://www.novitas-solutions.com
Cytogenetic Analysis Testing (Page 6 of 7)
CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249,
88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285,
88289, 88291, 88299, 88365, 88367, 88368
LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques,
and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to
confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
653.71
OTHER FETAL ABNORMALITY CAUSING
DISPROPORTION DELIVERED
653.73
OTHER FETAL ABNORMALITY CAUSING
DISPROPORTION ANTEPARTUM
655.00 - 655.23 CENTRAL NERVOUS SYSTEM MALFORMATION IN
FETUS UNSPECIFIED AS TO EPISODE OF CARE IN
PREGNANCY - HEREDITARY DISEASE IN FAMILY
POSSIBLY AFFECTING FETUS AFFECTING
MANAGEMENT OF MOTHER ANTEPARTUM
CONDITION OR COMPLICATION
656.40 - 656.63 INTRAUTERINE DEATH AFFECTING MANAGEMENT
OF MOTHER UNSPECIFIED AS TO EPISODE OF CARE
- EXCESSIVE FETAL GROWTH AFFECTING
MANAGEMENT OF MOTHER ANTEPARTUM
657.00 - 657.03 POLYHYDRAMNIOS UNSPECIFIED AS TO EPISODE
OF CARE - POLYHYDRAMNIOS ANTEPARTUM
COMPLICATION
658.00 - 658.03 OLIGOHYDRAMNIOS UNSPECIFIED AS TO EPISODE
OF CARE - OLIGOHYDRAMNIOS ANTEPARTUM
659.50 - 659.53 ELDERLY PRIMIGRAVIDA UNSPECIFIED AS TO
EPISODE OF CARE - ELDERLY PRIMIGRAVIDA
ANTEPARTUM
659.60 - 659.63 OTHER ADVANCED MATERNAL AGE
UNSPECIFIED AS TO EPISODE OF CARE OR NOT
APPLICABLE - OTHER ADVANCED MATERNAL
AGE ANTEPARTUM CONDITION OR
COMPLICATION
740.0 - 759.9 ANENCEPHALUS - CONGENITAL ANOMALY
UNSPECIFIED
764.90 - 764.99 FETAL GROWTH RETARDATION UNSPECIFIED
WEIGHT - FETAL GROWTH RETARDATION 2500
GRAMS AND OVER
779.9
UNSPECIFIED CONDITION ORIGINATING IN THE
PERINATAL PERIOD
783.22
UNDERWEIGHT
783.40 - 783.43 UNSPECIFIED LACK OF NORMAL
PHYSIOLOGICAL DEVELOPMENT - SHORT
STATURE
792.3
NONSPECIFIC ABNORMAL FINDINGS IN
AMNIOTIC FLUID
796.5
ABNORMAL FINDING ON ANTENATAL
SCREENING
796.6
NONSPECIFIC ABNORMAL FINDINGS ON
NEONATAL SCREENING
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Data Source: https://www.novitas-solutions.com
Cytogenetic Analysis Testing (Page 7 of 7)
CPT Code: 88120, 88121, 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, 88249,
88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285,
88289, 88291, 88299, 88365, 88367, 88368
LCD Description: Cytogenetics encompasses the study of cell structure with particular attention to chromosomal analysis. It includes cytogenetic banding techniques,
and molecular cytogenetic studies such as fluorescent in-situ Hybridization and comparative genomic hybridization. Karyotyping arranges nuclear chromosomes to
confirm number and structure. Further cytogenetic testing analyzes any abnormalities, particularly gain or loss of chromosomal material.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
996.81 - 996.87 COMPLICATIONS OF TRANSPLANTED KIDNEY COMPLICATIONS OF TRANSPLANTED ORGAN
INTESTINE
996.89
COMPLICATIONS OF OTHER SPECIFIED
TRANSPLANTED ORGAN
V13.61 - V13.69 PERSONAL HISTORY OF (CORRECTED)
HYPOSPADIAS - PERSONAL HISTORY OF OTHER
(CORRECTED) CONGENITAL MALFORMATIONS
V18.4
FAMILY HISTORY OF INTELLECTUAL DISABILITIES
V19.5
FAMILY HISTORY OF CONGENITAL ANOMALIES
V23.2
SUPERVISION OF HIGH-RISK PREGNANCY WITH
HISTORY OF ABORTION
V23.81 - V23.82 SUPERVISION OF HIGH-RISK PREGNANCY WITH
ELDERLY PRIMIGRAVIDA - SUPERVISION OF HIGHRISK PREGNANCY WITH ELDERLY MULTIGRAVIDA
V28.0 - V28.4 ANTENATAL SCREENING FOR CHROMOSOMAL
ANOMALIES BY AMNIOCENTESIS - ANTENATAL
SCREENING FOR FETAL GROWTH RETARDATION
USING ULTRASONICS
V49.89*
OTHER SPECIFIED CONDITIONS INFLUENCING
HEALTH STATUS
*288.01 Limited to infantile genetic agranulocytosis only
*V49.89 To be used only when repeat testing is believed to be
medically reasonable and necessary, and must be listed as
secondary with the primary neoplastic diagnosis.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Debridement of Mycotic Nails
CPT Code: 87101, 87102, 87220
Data Source: https://www.novitas-solutions.com
LCD Description: Fungal disease of the toenails is a comparatively benign condition, but difficult to eradicate due to a high recurrence rate. A superficial variety of fungal
infections produce little or no symptomatology beyond white opacities on the nails. However, deep infections may result in dystrophic nails, with subsequent pain and/or
limitation of ambulation, and/or secondary infection. The definitive treatment may involve a short-term use of oral agents, long term use of topical agents and/or periodic
debridement of the dystrophic fungal nails with thinning of the nail plates (manual or electric).
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes
book should be used as a complete reference.
Primary Diagnosis
110.1
DERMATOPHYTOSIS OF NAIL
Secondary Diagnosis
681.10
681.11
703.0
719.7
729.5
781.2
UNSPECIFIED CELLULITIS AND ABSCESS OF TOE
ONYCHIA AND PARONYCHIA OF TOE
INGROWING NAIL
DIFFICULTY IN WALKING
PAIN IN LIMB
ABNORMALITY OF GAIT
*According to Higmark Medicare, ICD-9-CM code 110.1 must appear on each claim in addition to one of the other above ICD-9-CM codes that indicates
secondary infection, pain, or difficulty in ambulation.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Flow Cytometry (1 of 4)
CPT Code: 88184, 88185, 88187, 88188, 88189
Data Source: https://www.novitas-solutions.com
LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important
immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The
technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical
analysis and interpretations are done by an experienced physician, usually a pathologist.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes
book should be used as a complete reference.
200.80 - 200.88
042
079.51 - 079.53
197.2
197.6
200.00 - 200.08
200.10 - 200.18
200.20 - 200.28
200.30 - 200.38
200.40 - 200.48
200.50 - 200.58
200.60 - 200.68
200.70 - 200.78
HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE
HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE I [HTLV-I] HUMAN IMMUNODEFICIENCY VIRUS TYPE 2 [HIV-2]
SECONDARY MALIGNANT NEOPLASM OF PLEURA
SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM
AND PERITONEUM
RETICULOSARCOMA UNSPECIFIED SITE - RETICULOSARCOMA
INVOLVING LYMPH NODES OF MULTIPLE SITES
LYMPHOSARCOMA UNSPECIFIED SITE - LYMPHOSARCOMA
INVOLVING LYMPH NODES OF MULTIPLE SITES
BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES
OF MULTIPLE SITES
MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE,
EXTRANODAL AND SOLID ORGAN SITES - MARGINAL ZONE
LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL
AND SOLID ORGAN SITES - MANTLE CELL LYMPHOMA, LYMPH
NODES OF MULTIPLE SITES
PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA,
UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH
NODES OF MULTIPLE SITES
ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE,
EXTRANODAL AND SOLID ORGAN SITES - ANAPLASTIC LARGE
CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL
AND SOLID ORGAN SITES - LARGE CELL LYMPHOMA, LYMPH
NODES OF MULTIPLE SITES
201.00 - 201.08
201.10 - 201.18
201.20 - 201.28
201.40 - 201.48
201.50 - 201.58
201.60 - 201.68
201.70 - 201.78
201.90 - 201.98
201.10 - 201.18
202.00 - 202.08
OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND
RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED
VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA
INVOLVING LYMPH NODES OF MULTIPLE SITES
HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES
OF MULTIPLE SITES
HODGKIN'S GRANULOMA UNSPECIFIED SITE - HODGKIN'S
GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
HODGKIN'S SARCOMA UNSPECIFIED SITE - HODGKIN'S
SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC
PREDOMINANCE UNSPECIFIED SITE - HODGKIN'S DISEASE
LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING
LYMPH NODES OF MULTIPLE SITES
HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED
SITE - HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING
LYMPH NODES OF MULTIPLE SITES
HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED
SITE - HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING
LYMPH NODES OF MULTIPLE SITES
HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION
UNSPECIFIED SITE - HODGKIN'S DISEASE LYMPHOCYTIC
DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES
HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED
SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING
LYMPH NODES OF MULTIPLE SITES
HODGKIN'S GRANULOMA UNSPECIFIED SITE - HODGKIN'S
GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR
LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Flow Cytometry (2 of 4)
CPT Code: 88184, 88185, 88187, 88188, 88189
Data Source: https://www.novitas-solutions.com
LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important
immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The
technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical
analysis and interpretations are done by an experienced physician, usually a pathologist.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes
book should be used as a complete reference.
203.80 - 203.82
202.20 - 202.28
202.30 - 202.38
202.40 - 202.48
202.50 - 202.58
202.60 - 202.68
202.70 - 202.78
202.80 - 202.88
202.90 - 202.98
203.00
203.02
203.10 - 203.12
SEZARY'S DISEASE UNSPECIFIED SITE - SEZARY'S DISEASE
INVOLVING LYMPH NODES OF MULTIPLE SITES
MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE - MALIGNANT
HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES
LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH
NODES OF MULTIPLE SITES
LETTERER-SIWE DISEASE UNSPECIFIED SITE - LETTERER-SIWE
DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES
MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF
MULTIPLE SITES
PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE,
EXTRANODAL AND SOLID ORGAN SITES - PERIPHERAL T CELL
LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER
MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF
MULTIPLE SITES
OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF
LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF
LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES
OF MULTIPLE SITES
MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED
REMISSION
MULTIPLE MYELOMA, IN RELAPSE
PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - PLASMA CELL LEUKEMIA, IN RELAPSE
204.00 - 204.02
204.10 - 204.12
204.20 - 204.22
204.80 - 204.82
204.90 - 204.92
205.00 - 205.02
205.10 - 205.12
205.20 - 205.22
205.30 - 205.32
205.80 - 205.82
OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT
MENTION OF HAVING ACHIEVED REMISSION - OTHER
IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE
ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - ACUTE LYMPHOID LEUKEMIA, IN
RELAPSE
CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION - CHRONIC LYMPHOID LEUKEMIA,
IN RELAPSE
SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION - SUBACUTE LYMPHOID
LEUKEMIA, IN RELAPSE
OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - OTHER LYMPHOID LEUKEMIA, IN
RELAPSE
UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION
OF HAVING ACHIEVED REMISSION - UNSPECIFIED LYMPHOID
LEUKEMIA, IN RELAPSE
ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - ACUTE MYELOID LEUKEMIA, IN
RELAPSE
CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - CHRONIC MYELOID LEUKEMIA, IN
RELAPSE
SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION - SUBACUTE MYELOID LEUKEMIA,
IN RELAPSE
MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED
REMISSION - MYELOID SARCOMA, IN RELAPSE
OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - OTHER MYELOID LEUKEMIA, IN RELAPSE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Flow Cytometry (3 of 4)
CPT Code: 88184, 88185, 88187, 88188, 88189
Data Source: https://www.novitas-solutions.com
LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important
immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The
technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical
analysis and interpretations are done by an experienced physician, usually a pathologist.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes
book should be used as a complete reference.
208.00 - 208.02
205.90 - 205.92
206.00 - 206.02
206.10 - 206.12
206.20 - 206.22
206.80 - 206.82
206.90 - 206.92
207.00 - 207.02
207.10 - 207.12
207.20 - 207.22
207.80 - 207.82
UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION - UNSPECIFIED MYELOID
LEUKEMIA, IN RELAPSE
ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - ACUTE MONOCYTIC LEUKEMIA, IN
RELAPSE
CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION - CHRONIC MONOCYTIC
LEUKEMIA, IN RELAPSE
SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION - SUBACUTE MONOCYTIC
LEUKEMIA, IN RELAPSE
OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - OTHER MONOCYTIC LEUKEMIA, IN
RELAPSE
UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF
HAVING ACHIEVED REMISSION - UNSPECIFIED MONOCYTIC
LEUKEMIA, IN RELAPSE
ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT
MENTION OF HAVING ACHIEVED REMISSION - ACUTE
ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE
CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - CHRONIC ERYTHREMIA, IN RELAPSE
MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - MEGAKARYOCYTIC LEUKEMIA, IN
RELAPSE
OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - OTHER SPECIFIED LEUKEMIA, IN
RELAPSE
208.10 - 208.12
208.20 - 208.22
208.80 - 208.82
208.90 - 208.92
238.71 - 238.77
238.79
273.1 - 273.3
273.8 - 273.9
279.00 - 279.06
279.09
279.10 - 279.13
279.19
279.2 - 279.3
279.41
279.49
ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT
MENTION OF HAVING ACHIEVED REMISSION - ACUTE
LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT
MENTION OF HAVING ACHIEVED REMISSION –
CHRONICLEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT
MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE
LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT
MENTION OF HAVING ACHIEVED REMISSION - OTHER
LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING
ACHIEVED REMISSION - UNSPECIFIED LEUKEMIA, IN RELAPSE
ESSENTIAL THROMBOCYTHEMIA - POST-TRANSPLANT
LYMPHOPROLIFERATIVE DISORDER (PTLD)
OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES
MONOCLONAL PARAPROTEINEMIA - MACROGLOBULINEMIA
OTHER DISORDERS OF PLASMA PROTEIN METABOLISM UNSPECIFIED DISORDER OF PLASMA PROTEIN METABOLISM
HYPOGAMMAGLOBULINEMIA UNSPECIFIED - COMMON
VARIABLE IMMUNODEFICIENCY
OTHER DEFICIENCY OF HUMORAL IMMUNITY
IMMUNODEFICIENCY WITH PREDOMINANT T-CELL DEFECT
UNSPECIFIED - NEZELOF'S SYNDROME
OTHER DEFICIENCY OF CELL-MEDIATED IMMUNITY
COMBINED IMMUNITY DEFICIENCY - UNSPECIFIED IMMUNITY
DEFICIENCY
AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME
AUTOIMMUNE DISEASE, NOT ELSEWHERE CLASSIFIE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Flow Cytometry (4 of 4)
CPT Code: 88184, 88185, 88187, 88188, 88189
Data Source: https://www.novitas-solutions.com
LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important
immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The
technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical
analysis and interpretations are done by an experienced physician, usually a pathologist.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes
book should be used as a complete reference.
288.8 - 288.9
OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS UNSPECIFIED DISEASE OF WHITE BLOOD CELLS
OTHER SPECIFIED DISORDERS INVOLVING THE IMMUNE
289.4
HYPERSPLENISM
MECHANISM - UNSPECIFIED DISORDER OF IMMUNE MECHANISM
289.50 - 289.53
DISEASE OF SPLEEN UNSPECIFIED – NEUTROPENIC
282.7
OTHER HEMOGLOBINOPATHIES
289.59
OTHER DISEASES OF SPLEEN
283.2
HEMOGLOBINURIA DUE TO HEMOLYSIS FROM EXTERNAL
289.83
MYELOFIBROSIS
CAUSES
289.9
UNSPECIFIED DISEASES OF BLOOD AND BLOOD-FORMING
284.01
CONSTITUTIONAL RED BLOOD CELL APLASIA
ORGANS
284.09
OTHER CONSTITUTIONAL APLASTIC ANEMIA
452
PORTAL VEIN THROMBOSIS
284.11 - 284.12
ANTINEOPLASTIC CHEMOTHERAPY INDUCED PANCYTOPENIA 453.9
EMBOLISM AND THROMBOSIS OF UNSPECIFIED SITE
OTHER DRUG INDUCED PANCYTOPENIA
785.6
ENLARGEMENT OF LYMPH NODES
284.19
OTHER PANCYTOPENIA
789.2
SPLENOMEGALY
284.2
MYELOPHTHISIS
791.0
PROTEINURIA
284.81
RED CELL APLASIA (ACQUIRED) (ADULT) (WITH THYMOMA)
795.4
OTHER NONSPECIFIC ABNORMAL HISTOLOGICAL FINDINGS
284.89
OTHER SPECIFIED APLASTIC ANEMIAS
996.80 - 996.89
COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN 284.9
APLASTIC ANEMIA UNSPECIFIED
COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN
285.0
SIDEROBLASTIC ANEMIA
V08
ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV)
285.22
ANEMIA IN NEOPLASTIC DISEASE
INFECTION STATUS
285.8 - 285.9
OTHER SPECIFIED ANEMIAS - ANEMIA UNSPECIFIED
V10.60 - V10.63
PERSONAL HISTORY OF UNSPECIFIED LEUKEMIA 287.30 - 287.33
PRIMARY THROMBOCYTOPENIA,UNSPECIFIED - CONGENITAL
PERSONAL HISTORY OF MONOCYTIC LEUKEMIA
AND EREDITARY THROMBOCYTOPENIC PURPURA
V10.69
PERSONAL HISTORY OF OTHER LEUKEMIA
287.39
OTHER PRIMARY THROMBOCYTOPENIA
V10.91
PERSONAL HISTORY OF MALIGNANT NEUROENDOCRINE
287.5
THROMBOCYTOPENIA UNSPECIFIED
TUMOR
288.00 - 288.04
NEUTROPENIA, UNSPECIFIED - NEUTROPENIA DUE TO
V42.0 - V42.7
KIDNEY REPLACED BY TRANSPLANT - LIVER REPLACED BY
INFECTION
TRANSPLANT
288.09
OTHER NEUTROPENIA
V42.81 - V42.84
BONE MARROW REPLACED BY TRANSPLANT - ORGAN OR
288.1 - 288.4
FUNCTIONAL DISORDERS OF POLYMORPHONUCLEAR
TISSUE REPLACED BY TRANSPLANT INTESTINES
NEUTROPHILS - HEMOPHAGOCYTIC SYNDROMES
V42.89
OTHER SPECIFIED ORGAN OR TISSUE REPLACED BY
288.50 - 288.51
LEUKOCYTOPENIA, UNSPECIFIED – LYMPHOCYTOPENIA
TRANSPLANT
288.59
OTHER DECREASED WHITE BLOOD CELL COUNT
V42.9
UNSPECIFIED ORGAN OR TISSUE REPLACED BY TRANSPLANT
288.60 - 288.65
LEUKOCYTOSIS, UNSPECIFIED – BASOPHILIA
SPLENOMEGALY
288.69
OTHER ELEVATED WHITE BLOOD CELL COUNT
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
279.8 - 279.9
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Flow Cytometry: Cell Cycle or DNA Analysis
CPT Code: 88182
Data Source: https://www.novitas-solutions.com
LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important
immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The
technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical
analysis and interpretations are done by an experienced physician, usually a pathologist.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes
book should be used as a complete reference.
150.0 - 150.5
150.8 - 150.9
151.0 - 151.6
151.8 - 151.9
153.0 - 153.9
154.0
154.1
174.0 - 174.6
174.8 - 174.9
175.0
175.9
183.0
183.8
185
188.0
188.1 - 188.9
193
194.0
198.81
227.0
233.0
259.2
MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS
MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE
MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE
MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE
MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION
MALIGNANT NEOPLASM OF RECTUM
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST
MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST
MALIGNANT NEOPLASM OF OVARY
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA
MALIGNANT NEOPLASM OF PROSTATE
MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER
MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER - MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED
MALIGNANT NEOPLASM OF THYROID GLAND
MALIGNANT NEOPLASM OF ADRENAL GLAND
SECONDARY MALIGNANT NEOPLASM OF BREAST
BENIGN NEOPLASM OF ADRENAL GLAND
CARCINOMA IN SITU OF BREAST
CARCINOID SYNDROME
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
ImmunoCAP(R) Radioallergosorbent Test, Fluoroallergosorbent Testing (1 of 2)
CPT Code: 86003
Data Source: https://www.novitas-solutions.com
LCD Description: ImmunoCAP(R) radioallergosorbent test, fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for
determining whether a patients serum contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is
based on the findings during a complete history and physical examination of the patient.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
477.0
477.1
477.2
477.8
477.9
493.00
493.01
493.02
493.82
493.90
493.91
493.92
691.8
708.0
708.8
708.9
786.07
ALLERGIC RHINITIS DUE TO POLLEN
ALLERGIC RHINITIS DUE TO FOOD
ALLERGIC RHINITIS, DUE TO ANIMAL (CAT) (DOG)
HAIR AND DANDER
ALLERGIC RHINITIS DUE TO OTHER ALLERGEN
ALLERGIC RHINITIS CAUSE UNSPECIFIED
EXTRINSIC ASTHMA UNSPECIFIED
EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS
EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION
COUGH VARIANT ASTHMA
ASTHMA UNSPECIFIED
ASTHMA UNSPECIFIED TYPE WITH STATUS
ASTHMATICUS
ASTHMA UNSPECIFIED WITH (ACUTE)
EXACERBATION
OTHER ATOPIC DERMATITIS AND RELATED
CONDITIONS
ALLERGIC URTICARIA
OTHER SPECIFIED URTICARIA
UNSPECIFIED URTICARIA
WHEEZING
989.5*
995.0
995.1
995.20
995.22
995.27
995.29
995.3
995.60
995.61
995.62
995.63
TOXIC EFFECT OF VENOM
OTHER ANAPHYLACTIC SHOCK NOT ELSEWHERE
CLASSIFIED
ANGIONEUROTIC EDEMA NOT ELSEWHERE
CLASSIFIED
UNSPECIFIED ADVERSE EFFECT OF
UNSPECIFIED DRUG, MEDICINAL AND
BIOLOGICAL SUBSTANCE
UNSPECIFIED ADVERSE EFFECT OF ANESTHESIA
OTHER DRUG ALLERGY
UNSPECIFIED ADVERSE EFFECT OF OTHER
DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE
ALLERGY UNSPECIFIED NOT ELSEWHERE
CLASSIFIED
ANAPHYLACTIC SHOCK DUE TO UNSPECIFIED
FOOD
ANAPHYLACTIC SHOCK DUE TO PEANUTS
ANAPHYLACTIC SHOCK DUE TO CRUSTACEANS
ANAPHYLACTIC SHOCK DUE TO FRUITS AND
VEGETABLES
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
ImmunoCAP(R) Radioallergosorbent Test, Fluoroallergosorbent Testing (2 of 2)
Data Source: https://www.novitas-solutions.com
CPT Code: 86003
LCD Description: ImmunoCAP(R) radioallergosorbent test, fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for
determining whether a patients serum contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is
based on the findings during a complete history and physical examination of the patient.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
995.64
995.65
995.66
995.67
995.68
995.69
V15.09
ANAPHYLACTIC SHOCK DUE TO TREE NUTS AND
SEEDS
ANAPHYLACTIC SHOCK DUE TO FISH
ANAPHYLACTIC SHOCK DUE TO FOOD ADDITIVES
ANAPHYLACTIC SHOCK DUE TO MILK PRODUCTS
ANAPHYLACTIC SHOCK DUE TO EGGS
ANAPHYLACTIC SHOCK DUE TO OTHER
SPECIFIED
FOOD
PERSONAL HISTORY OF OTHER ALLERGY OTHER
THAN TO MEDICINAL AGENTS
Utilization Guidelines
CPT code 86003 will be covered for only thirty (30) units in a year. Services
exceeding this parameter will be considered not medically necessary. Claims for
RAST, FAST, ELISA, or multiple antigen simultaneous testing for specific IgE
should be processed under CPT code 86003.
Per Novitas Medicare the following tests are considered to
be not medically necessary and will be denied:
IgG ELISA, indirect method (CPT code 86001)
Qualitative multi-allergen screen (CPT code 86005)-This is
a non-specific test that does not identify a specific antigen.
According to the Medicare Local Coverage Determination
policy, IgG and IgG subclass antibody tests for food allergy
do not have clinical relevance, are not validated, lack
sufficient quality control, and should not be performed.
*ICD-9-CM code 989.5 should be reported for venom
hypersensitivity.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Moh’s Micrographic Surgery (1 of 2)
CPT Code: 88304, 88305, 88307, 88331, 88332, 88342
Data Source: https://www.novitas-solutions.com
LCD Description: Moh’s Micrographic Surgery (MMS) is a microscopically controlled tissue-sparing surgical technique of removing complex or ill-defined cancerous
tissues of the skin. The surgery is usually performed in an outpatient setting under local anesthesia, with or without sedation.
MMS involves obtaining of tangential specimen of tumor with a minimal margin of clinically normal-appearing tissue, precisely mapped, and processed immediately by
frozen section for microscopic examination. This process of removal of complex or ill-defined skin cancer requires a single physician to act in two integrated, but
separate and distinct capacities: surgeon and pathologist, trained and highly skilled in MMS techniques and pathology identification.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM
Codes book should be used as a complete reference.
140.0 - 140.9
141.0 - 141.9
144.0 - 144.9
145.0 - 145.9
160.0
160.2 - 160.9
161.0 - 161.9
171.0 - 171.9
172.0 - 172.9
173.00 - 173.99
184.1 - 184.9
187.1 - 187.4
MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION
BORDER
MALIGNANT NEOPLASM OF BASE OF TONGUE - MALIGNANT
NEOPLASM OF TONGUE UNSPECIFIED
MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR
OF MOUTH - MALIGNANT NEOPLASM OF FLOOR OF MOUTH
PART UNSPECIFIED
MALIGNANT NEOPLASM OF CHEEK MUCOSA - MALIGNANT
NEOPLASM OF MOUTH UNSPECIFIED
MALIGNANT NEOPLASM OF NASAL CAVITIES
MALIGNANT NEOPLASM OF MAXILLARY SINUS - MALIGNANT
NEOPLASM OF ACCESSORY SINUS UNSPECIFIED
MALIGNANT NEOPLASM OF GLOTTIS – MALIGNANT NEOPLASM
OF LARYNX UNSPECIFIED
MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT
TISSUE OF HEAD FACE AND NECK - MALIGNANT NEOPLASM
OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED
MALIGNANT MELANOMA OF SKIN OF LIP - MELANOMA OF SKIN
SITE UNSPECIFIED
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP - OTHER
SPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE
UNSPECIFIED
MALIGNANT NEOPLASM OF LABIA MAJORA - MALIGNANT
NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED
MALIGNANT NEOPLASM OF PREPUCE - MALIGNANT
NEOPLASM OF PENIS PART UNSPECIFIED
187.7 - 187.9
209.30 - 209.36
232.0 - 232.9
233.31
233.32
233.39
233.6
238.1
238.2
279.00 - 279.9
440.0
440.1
440.20
440.21
440.22
440.23
MALIGNANT NEOPLASM OF SCROTUM - MALIGNANT NEOPLASM
OF MALE GENITAL ORGAN SITE UNSPECIFIED
MALIGNANT POORLY DIFFERENTIATED NEUROENDOCRINE
CARCINOMA, ANY SITE - MERKEL CELL CARCINOMA OF OTHER
SITES
CARCINOMA IN SITU OF SKIN OF LIP - CARCINOMA IN SITU OF
SKIN SITE UNSPECIFIED
CARCINOMA IN SITU, VAGINA
CARCINOMA IN SITU, VULVA
CARCINOMA IN SITU, OTHER FEMALE GENITAL ORGAN
CARCINOMA IN SITU OF OTHER AND UNSPECIFIED MALE
GENITAL ORGANS
NEOPLASM OF UNCERTAIN BEHAVIOR OF CONNECTIVE AND
OTHER SOFT TISSUE
NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN
HYPOGAMMAGLOBULINEMIA UNSPECIFIED - UNSPECIFIED
DISORDER OF IMMUNE MECHANISM
ATHEROSCLEROSIS OF AORTA
ATHEROSCLEROSIS OF RENAL ARTERY
ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE
EXTREMITIES UNSPECIFIED
ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE
EXTREMITIES WITH INTERMITTENT CLAUDICATION
ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE
EXTREMITIES WITH REST PAIN
ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE
EXTREMITIES WITH ULCERATION
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Moh’s Micrographic Surgery (2 of 2)
CPT Code: 88304, 88305, 88307, 88331, 88332, 88342
Data Source: https://www.novitas-solutions.com
LCD Description: Moh’s Micrographic Surgery (MMS) is a microscopically controlled tissue-sparing surgical technique of removing complex or ill-defined cancerous tissues of the skin.
The surgery is usually performed in an outpatient setting under local anesthesia, with or without sedation.
MMS involves obtaining of tangential specimen of tumor with a minimal margin of clinically normal-appearing tissue, precisely mapped, and processed immediately by frozen section for
microscopic examination. This process of removal of complex or ill-defined skin cancer requires a single physician to act in two integrated, but separate and distinct capacities: surgeon
and pathologist, trained and highly skilled in MMS techniques and pathology identification.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM
book should be used as a complete reference.
440.24
440.29
440.30
440.31
440.32
440.4
440.8
440.9
443.1
443.81
443.82
443.89
443.9
444.22
444.81
451.0
451.11
ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE
EXTREMITIES WITH GANGRENE
OTHER ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE
EXTREMITIES
ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE
EXTREMITIES
ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT
OF THE EXTREMITIES
ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL
BYPASS GRAFT OF THE EXTREMITIES
CHRONIC TOTAL OCCLUSION OF ARTERY OF THE
EXTREMITIES
ATHEROSCLEROSIS OF OTHER SPECIFIED ARTERIES
GENERALIZED AND UNSPECIFIED ATHEROSCLEROSIS
THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE)
PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED
ELSEWHERE
ERYTHROMELALGIA
OTHER PERIPHERAL VASCULAR DISEASE
PERIPHERAL VASCULAR DISEASE UNSPECIFIED
ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER
EXTREMITY
EMBOLISM AND THROMBOSIS OF ILIAC ARTERY
PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL
VESSELS OF LOWER EXTREMITIES
PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN
(DEEP) (SUPERFICIAL)
451.19
451.2
454.0 - 454.9
457.0
457.1
459.10 - 459.19
459.2
459.81
459.89
692.82
757.0
782.3
940.0 - 940.5
PHLEBITIS AND THROMBOPHLEBITIS OF OTHER
PHLEBITIS AND THROMBOPHLEBITIS OF LOWER
EXTREMITIES UNSPECIFIED
VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER ASYMPTOMATIC VARICOSE VEINS
POSTMASTECTOMY LYMPHEDEMA SYNDROME
OTHER LYMPHEDEMA
POSTPHLEBETIC SYNDROME WITHOUT COMPLICATIONS POSTPHLEBETIC SYNDROME WITH OTHER COMPLICATION
COMPRESSION OF VEIN
VENOUS (PERIPHERAL) INSUFFICIENCY UNSPECIFIED
OTHER SPECIFIED CIRCULATORY SYSTEM DISORDERS
DERMATITIS DUE TO OTHER RADIATION
HEREDITARY EDEMA OF LEGS
EDEMA
CHEMICAL BURN OF EYELIDS AND PERIOCULAR AREA BURN WITH RESULTING RUPTURE AND DESTRUCTION OF
EYEBALL
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Molecular Diagnostics: Genitourinary Infectious Disease (1 of 3)
CPT Code: 87480, 87490, 87491, 87510, 87590, 87591, 87660 Data Source: https://www.novitas-solutions.com
LCD Description: Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, provides sensitive, specific and
timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The limited coverage
table below denotes infectious disease manifestations in the area of genitourinary (“GU”) testing for those organisms where specific CPT codes exist versus organisms
which would require non-specific coding .
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes
book should be used as a complete reference.
076.0 - 076.1
076.9
077.0
077.98 - 077.99
098.0
098.10 - 098.17
098.19
098.2
098.30 - 098.37
098.39
098.40 - 098.43
098.49
098.50 - 098.53
098.59
098.6 - 098.7
TRACHOMA INITIAL STAGE - TRACHOMA ACTIVE STAGE
TRACHOMA UNSPECIFIED
INCLUSION CONJUNCTIVITIS
UNSPECIFIED DISEASES OF CONJUNCTIVA DUE TO
CHLAMYDIAE - UNSPECIFIED DISEASES OF CONJUNCTIVA
DUE TO VIRUSES
GONOCOCCAL INFECTION (ACUTE) OF LOWER
GENITOURINARY TRACT
GONOCOCCAL INFECTION (ACUTE) OF UPPER
GENITOURINARY TRACT SITE UNSPECIFIED GONOCOCCAL SALPINGITIS SPECIFIED AS ACUTE
OTHER GONOCOCCAL INFECTION (ACUTE) OF UPPER
GENITOURINARY TRACT
GONOCOCCAL INFECTION CHRONIC OF LOWER
GENITOURINARY TRACT
CHRONIC GONOCOCCAL INFECTION OF UPPER
GENITOURINARY TRACT SITE UNSPECIFIED GONOCOCCAL SALPINGITIS (CHRONIC)
OTHER CHRONIC GONOCOCCAL INFECTION OF UPPER
GENITOURINARY TRACT
GONOCOCCAL CONJUNCTIVITIS (NEONATORUM) GONOCOCCAL KERATITIS
OTHER GONOCOCCAL INFECTION OF EYE
GONOCOCCAL ARTHRITIS - GONOCOCCAL SPONDYLITIS
OTHER GONOCOCCAL INFECTION OF JOINT
GONOCOCCAL INFECTION OF PHARYNX GONOCOCCAL INFECTION OF ANUS AND RECTUM
098.81 - 098.86
098.89
099.1
099.3
099.41
099.50 - 099.56
099.59
112.1 - 112.2
131.00 - 131.03
131.09
131.8 - 131.9
288.00 - 288.04
288.09
288.66
288.8
289.1
289.53
289.83
372.00
GONOCOCCAL KERATOSIS (BLENNORRHAGICA) GONOCOCCAL PERITONITIS
GONOCOCCAL INFECTION OF OTHER SPECIFIED SITES
LYMPHOGRANULOMA VENEREUM
REITER'S DISEASE
OTHER NONGONOCOCCAL URETHRITIS CHLAMYDIA
TRACHOMATIS
OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS
UNSPECIFIED SITE - OTHER VENEREAL DISEASES DUE TO
CHLAMYDIA TRACHOMATIS PERITONEUM
OTHER VENEREAL DISEASES DUE TO CHLAMYDIA TRACHOMATIS
OTHER SPECIFIED SITE
CANDIDIASIS OF VULVA AND VAGINA - CANDIDIASIS OF OTHER
UROGENITAL SITES
UROGENITAL TRICHOMONIASIS UNSPECIFIED - TRICHOMONAL
PROSTATITIS
OTHER UROGENITAL TRICHOMONIASIS
TRICHOMONIASIS OF OTHER SPECIFIED SITES TRICHOMONIASIS UNSPECIFIED
NEUTROPENIA, UNSPECIFIED - NEUTROPENIA DUE TO INFECTION
OTHER NEUTROPENIA
BANDEMIA
OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS
CHRONIC LYMPHADENITIS
NEUTROPENIC SPLENOMEGALY
MYELOFIBROSIS
ACUTE CONJUNCTIVITIS UNSPECIFIED
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Molecular Diagnostics: Genitourinary Infectious Disease (2 of 3)
CPT Code: 87480, 87490, 87491, 87510, 87590, 87591, 87660 Data Source: https://www.novitas-solutions.com
LCD Description: Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, provides sensitive, specific and
timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The limited coverage
table below denotes infectious disease manifestations in the area of genitourinary (“GU”) testing for those organisms where specific CPT codes exist versus organisms
which would require non-specific coding .
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes
book should be used as a complete reference.
372.02 - 372.03
372.10 - 372.12
595.4
597.80 - 597.81
601.0
601.8 - 601.9
604.0
604.90 - 604.91
608.89
614.0
614.2 - 614.4
614.6
614.8 - 614.9
616.0
616.81
616.89
ACUTE FOLLICULAR CONJUNCTIVITIS - OTHER
MUCOPURULENT CONJUNCTIVITIS
CHRONIC CONJUNCTIVITIS UNSPECIFIED - CHRONIC
FOLLICULAR CONJUNCTIVITIS
CYSTITIS IN DISEASES CLASSIFIED ELSEWHERE
URETHRITIS UNSPECIFIED - URETHRAL SYNDROME NOS
ACUTE PROSTATITIS
OTHER SPECIFIED INFLAMMATORY DISEASES OF PROSTATEPROSTATITIS UNSPECIFIED
ORCHITIS EPIDIDYMITIS AND EPIDIDYMO-ORCHITIS WITH
ABSCESS
ORCHITIS AND EPIDIDYMITIS UNSPECIFIED - ORCHITIS AND
EPIDIDYMITIS IN DISEASES CLASSIFIED ELSEWHERE
OTHER SPECIFIED DISORDERS OF MALE GENITAL ORGANS
ACUTE SALPINGITIS AND OOPHORITIS
SALPINGITIS AND OOPHORITIS NOT SPECIFIED AS ACUTE
SUBACUTE OR CHRONIC - CHRONIC OR UNSPECIFIED
PARAMETRITIS AND PELVIC CELLULITIS
PELVIC PERITONEAL ADHESIONS FEMALE
(POSTOPERATIVE) (POSTINFECTION)
OTHER SPECIFIED INFLAMMATORY DISEASE OF FEMALE
PELVIC ORGANS AND TISSUES - UNSPECIFIED
INFLAMMATORY DISEASE OF FEMALE PELVIC ORGANS AND
TISSUES
CERVICITIS AND ENDOCERVICITIS
MUCOSITIS (ULCERATIVE) OF CERVIX, VAGINA, AND VULVA
OTHER INFLAMMATORY DISEASE OF CERVIX, VAGINA AND
VULVA
616.9
628.2
629.89
683
711.90 - 711.99
716.50 - 716.59
716.60 - 716.68
716.90 - 716.99
719.40 - 719.49
727.00
727.05 - 727.06
727.09
771.6
780.60 - 780.61
782.1
785.6
788.1
UNSPECIFIED INFLAMMATORY DISEASE OF CERVIX VAGINA
AND VULVA
INFERTILITY FEMALE OF TUBAL ORIGIN
OTHER SPECIFIED DISORDERS OF FEMALE GENITAL ORGANS
ACUTE LYMPHADENITIS
UNSPECIFIED INFECTIVE ARTHRITIS SITE UNSPECIFIED UNSPECIFIED INFECTIVE ARTHRITIS INVOLVING MULTIPLE
SITES
UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS SITE
UNSPECIFIED - UNSPECIFIED POLYARTHROPATHY OR
POLYARTHRITIS INVOLVING MULTIPLE SITES
UNSPECIFIED MONOARTHRITIS SITE UNSPECIFIED UNSPECIFIED MONOARTHRITIS INVOLVING OTHER SPECIFIED
SITES
UNSPECIFIED ARTHROPATHY SITE UNSPECIFIED UNSPECIFIED ARTHROPATHY INVOLVING MULTIPLE SITES
PAIN IN JOINT SITE UNSPECIFIED - PAIN IN JOINT INVOLVING
MULTIPLE SITES
SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED
OTHER TENOSYNOVITIS OF HAND AND WRIST - TENOSYNOVITIS
OF FOOT AND ANKLE
OTHER SYNOVITIS AND TENOSYNOVITIS
NEONATAL CONJUNCTIVITIS AND DACRYOCYSTITIS
FEVER, UNSPECIFIED - FEVER PRESENTING WITH CONDITIONS
CLASSIFIED ELSEWHERE
RASH AND OTHER NONSPECIFIC SKIN ERUPTION
ENLARGEMENT OF LYMPH NODES
DYSURIA
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Molecular Diagnostics: Genitourinary Infectious Disease (3 of 3)
CPT Code: 87480, 87490, 87491, 87510, 87590, 87591, 87660 Data Source: https://www.novitas-solutions.com
LCD Description: Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, provides sensitive, specific and
timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The limited coverage
table below denotes infectious disease manifestations in the area of genitourinary (“GU”) testing for those organisms where specific CPT codes exist versus organisms
which would require non-specific coding .
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes
book should be used as a complete reference.
788.64 - 788.65
788.7
789.00 - 789.07
789.09
789.1 - 789.2
789.30 - 789.37
789.39
789.40 - 789.47
RIGIDITY
789.49
789.51
789.59
789.60 - 789.67
789.69
789.9
790.4 - 790.5
790.7
791.0 - 791.7
791.9
URINARY HESITANCY - STRAINING ON URINATION
URETHRAL DISCHARGE
ABDOMINAL PAIN UNSPECIFIED SITE - ABDOMINAL PAIN
GENERALIZED
ABDOMINAL PAIN OTHER SPECIFIED SITE
HEPATOMEGALY - SPLENOMEGALY
ABDOMINAL OR PELVIC SWELLING MASS OR LUMP
UNSPECIFIED SITE - ABDOMINAL OR PELVIC SWELLING
MASS OR LUMP GENERALIZED
ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER
SPECIFIED SITE
ABDOMINAL RIGIDITY UNSPECIFIED SITE - ABDOMINAL
GENERALIZED
ABDOMINAL RIGIDITY OTHER SPECIFIED SITE
MALIGNANT ASCITES
OTHER ASCITES
ABDOMINAL TENDERNESS UNSPECIFIED SITE - ABDOMINAL
TENDERNESS GENERALIZED
ABDOMINAL TENDERNESS OTHER SPECIFIED SITE
OTHER SYMPTOMS INVOLVING ABDOMEN AND PELVIS
NONSPECIFIC ELEVATION OF LEVELS OF TRANSAMINASE OR
LACTIC ACID DEHYDROGENASE (LDH) - OTHER NONSPECIFIC
ABNORMAL SERUM ENZYME LEVELS
BACTEREMIA
PROTEINURIA - OTHER CELLS AND CASTS IN URINE
OTHER NONSPECIFIC FINDINGS ON EXAMINATION OF URINE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Molecular Diagnostics: Human Papillomavirus
CPT Code: 87621
Data Source: https://www.novitas-solutions.com
LCD Description: Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, provides sensitive, specific and
timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The limited coverage
table below denotes infectious disease manifestations in the area of genitourinary (“GU”) testing for those organisms where specific CPT codes exist versus organisms
which would require non-specific coding .
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes
book should be used as a complete reference.
622.10 - 622.12
795.00 - 795.01
CELLS OF
795.03
DYSPLASIA OF CERVIX, UNSPECIFIED - MODERATE DYSPLASIA OF CERVIX
ABNORMAL GLANDULAR PAPANICOLAOU SMEAR OF CERVIX - PAPANICOLAOU SMEAR OF CERVIX WITH ATYPICAL SQUAMOUS
UNDETERMINED SIGNIFICANCE (ASC-US)
PAPANICOLAOU SMEAR OF CERVIX WITH LOW GRADE SQUAMOUS INTRAEPITHELIAL LESION (LGSIL)
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Molecular Diagnostics: Not otherwise specified
CPT Code: 87798
Data Source: https://www.novitas-solutions.com
LCD Description: Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, provides sensitive, specific and
timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The limited coverage
table below denotes infectious disease manifestations in the area of genitourinary (“GU”) testing for those organisms where specific CPT codes exist versus organisms
which would require non-specific coding .
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes
book should be used as a complete reference.
033.0
053.0 - 053.9
058.82
066.40
075
079.51
079.83
079.89
082.40 - 082.49
085.1 - 085.9
088.82
130.9
WHOOPING COUGH DUE TO BORDETELLA PERTUSSIS (B. PERTUSSIS)
HERPES ZOSTER WITH MENINGITIS - HERPES ZOSTER WITHOUT COMPLICATION
HUMAN HERPESVIRUS 7 INFECTION
WEST NILE FEVER, UNSPECIFIED
INFECTIOUS MONONUCLEOSIS
HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE I [HTLV-I]
PARVOVIRUSB19
OTHER SPECIFIED VIRAL INFECTION
UNSPECIFIED EHRLICHIOSIS - OTHER EHRLICHIOSIS
CUTANEOUS LEISHMANIASIS URBAN - LEISHMANIASIS UNSPECIFIED
BABESIOSIS
TOXOPLASMOSIS UNSPECIFIED
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
11/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
OVA-1 Assay
Data Source: https://www.novitas-solutions.com
CPT Code: 84999
LCD Description: The OVA-1 test is specifically indicated for the pre-surgical evaluation of women with an ovarian mass, and suspicion of an ovarian neoplasm. It uses
the results of 5 known biomarkers (B-2 microglobulin, apolipoprotein A1, CA 125, transferrin, and transthyretin (prealbumin) to generate a numerical score that
correlates with the likelihood of malignancy. It is not a screening study, and should not be used in women with a diagnosis of malignancy in the past five years. It
should also not be used in women under age 18, or with a rheumatoid factor concentration of greater than or equal to 250 IU/ml. It is expected that the use of this test
will be followed in a timely fashion by an appropriate diagnostic study to confirm a pathologic diagnosis.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
789.33 - 789.34 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP RIGHT LOWER QUADRANT ABDOMINAL OR PELVIC SWELLING MASS OR LUMP LEFT LOWER QUADRANT
Utilization Guidelines
It is expected that this study will be ordered once prior to the appropriate diagnostic study with appropriate pathologic diagnosis recorded as
above.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
PARATHORMONE (PARATHYROID HORMONE)
CPT Code: 83970
Data Source: https://www.novitas-solutions.com
LCD Description: Parathyroid hormone (PTH), a polypeptide hormone produced in the parathyroid gland, along with Vitamin D, is the principal regulator of calcium and
phosphorus homeostasis. The most important actions of PTH are (1) rapid mobilization of calcium and phosphate from bone and long-term acceleration of bone
resorption, (2) increasing renal tubular reabsorption of calcium, (3) increasing intestinal absorption of calcium (mediated by an action on the metabolism of vitamin D),
and (4) decreasing renal tubular reabsorption of phosphate. These actions account for most of the important clinical manifestations of PTH excess or deficiency.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
227.1
BENIGN NEOPLASM OF PARATHYROID GLAND
252.00 - 252.9 HYPERPARATHYROIDISM, UNSPECIFIED UNSPECIFIED DISORDER OF PARATHYROID GLAND
268.0 - 268.9 RICKETS ACTIVE - UNSPECIFIED VITAMIN D
DEFICIENCY
269.2
UNSPECIFIED VITAMIN DEFICIENCY
275.2
DISORDERS OF MAGNESIUM METABOLISM
275.3
DISORDERS OF PHOSPHORUS METABOLISM
275.40 - 275.49 UNSPECIFIED DISORDER OF CALCIUM METABOLISM
- OTHER DISORDERS OF CALCIUM METABOLISM
278.4
HYPERVITAMINOSIS D
579.0
CELIAC DISEASE
585.1 - 585.9 CHRONIC KIDNEY DISEASE, STAGE I - CHRONIC
KIDNEY
DISEASE, UNSPECIFIED
586
RENAL FAILURE UNSPECIFIED
588.0
RENAL OSTEODYSTROPHY
588.81
SECONDARY HYPERPARATHYROIDISM (OF RENAL
ORIGIN)
592.0 - 592.9 CALCULUS OF KIDNEY - URINARY CALCULUS
UNSPECIFIED
731.0
OSTEITIS DEFORMANS WITHOUT BONE TUMOR
733.00 – 733.09OSTEOPOROSIS UNSPECIFIED - OTHER
OSTEOPOROSIS
733.29
733.90
733.91
733.93
733.95
733.99
781.7
791.9*
V58.44
V67.00*
V77.99*
OTHER BONE CYST
DISORDER OF BONE AND CARTILAGE
UNSPECIFIED
ARREST OF BONE DEVELOPMENT OR GROWTH
STRESS FRACTURE OF TIBIA OR FIBULA
STRESS FRACTURE OF OTHER BONE
OTHER DISORDERS OF BONE AND CARTILAGE
TETANY
OTHER NONSPECIFIC FINDINGS ON
EXAMINATION OF URINE
AFTERCARE FOLLOWING ORGAN TRANSPLANT
FOLLOW-UP EXAMINATION FOLLOWING
UNSPECIFIED SURGERY
SCREENING FOR OTHER AND UNSPECIFIED
ENDOCRINE NUTRITIONAL METABOLIC AND
IMMUNITY DISORDERS
Note: per Novitas Medicare LCD policy ICD-9-CM code 791.9 should
be used for patients with hypercalciuria. ICD-9-CM code V77.99
should be used for parathormone measurements performed during
parathyroidectomy in the operating room. ICD-9-CM code V67.00
may be used for medically necessary parathormone measurements in
the post operative period.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Qualitative Drug Testing (Page 1 of 2)
Data Source: https://www.highmarkmedicareservices.com
CPT Code: 80102, G0431, G0434
LCD Description: A qualitative drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. However, urine is the best
specimen for broad qualitative screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
276.2
295.00
295.10
295.20
295.30
304.01
304.90
305.90
345.10
345.11
345.3
345.90
345.91
426.10
426.11
426.12
426.13
426.82
ACIDOSIS
SIMPLE TYPE SCHIZOPHRENIA UNSPECIFIED STATE
DISORGANIZED TYPE SCHIZOPHRENIA UNSPECIFIED
STATE
CATATONIC TYPE SCHIZOPHRENIA UNSPECIFIED
STATE
PARANOID TYPE SCHIZOPHRENIA UNSPECIFIED STATE
OPIOID TYPE DEPENDENCE CONTINUOUS USE
UNSPECIFIED DRUG DEPENDENCE UNSPECIFIED
USE
OTHER MIXED OR UNSPECIFIED DRUG ABUSE
UNSPECIFIED USE
GENERALIZED CONVULSIVE EPILEPSY WITHOUT
INTRACTABLE EPILEPSY
GENERALIZED CONVULSIVE EPILEPSY WITH
INTRACTABLE EPILEPSY
GRAND MAL STATUS EPILEPTIC
EPILEPSY UNSPECIFIED WITHOUT INTRACTABLE
EPILEPSY
EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY
ATRIOVENTRICULAR BLOCK UNSPECIFIED
FIRST DEGREE ATRIOVENTRICULAR BLOCK
MOBITZ (TYPE) II ATRIOVENTRICULAR BLOCK
OTHER SECOND DEGREE ATRIOVENTRICULAR BLOCK
LONG QT SYNDROME
427.0
427.1
780.01
780.09
780.1
780.39
780.97
963.0
965.00
965.01
965.02
965.09
965.1
965.4
965.5
965.61
966.1
967.0
967.1
967.2
967.3
PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
PAROXYSMAL VENTRICULAR TACHYCARDIA
COMA
ALTERATION OF CONSCIOUSNESS OTHER
HALLUCINATIONS
OTHER CONVULSIONS
ALTERED MENTAL STATUS
POISONING BY ANTIALLERGIC AND ANTIEMETIC
DRUGS
POISONING BY OPIUM (ALKALOIDS) UNSPECIFIED
POISONING BY HEROIN
POISONING BY METHADONE
POISONING BY OTHER OPIATES AND RELATED
NARCOTICS
POISONING BY SALICYLATES
POISONING BY AROMATIC ANALGESICS NOT
ELSEWHERE CLASSIFIED
POISONING BY PYRAZOLE DERIVATIVES
POISONING BY PROPIONIC ACID DERIVATIVES
POISONING BY HYDANTOIN DERIVATIVES
POISONING BY BARBITURATES
POISONING BY CHLORAL HYDRATE GROUP
POISONING BY PARALDEHYDE
POISONING BY BROMINE COMPOUNDS
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
5/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Qualitative Drug Testing (Page 2 of 2)
Data Source: https://www.highmarkmedicareservices.com
CPT Code: 80102, G0431, G0434
LCD Description: A qualitative drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. However, urine is the best
specimen for broad qualitative screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be
present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
967.4
967.5
967.6
967.8
967.9
969.00
969.01
969.02
969.03
969.04
969.05
969.09
969.1
969.2
969.3
969.4
969.5
POISONING BY METHAQUALONE COMPOUNDS
POISONING BY GLUTETHIMIDE GROUP
POISONING BY MIXED SEDATIVES NOT ELSEWHERE
CLASSIFIED
POISONING BY OTHER SEDATIVES AND HYPNOTICS
POISONING BY UNSPECIFIED SEDATIVE OR
HYPNOTIC
POISONING BY ANTIDEPRESSANT, UNSPECIFIED
POISONING BY MONOAMINE OXIDASE INHIBITORS
POISONING BY SELECTIVE SEROTONIN AND
NOREPINEPHRINE REUPTAKE INHIBITORS
POISONING BY SELECTIVE SEROTONIN REUPTAKE
INHIBITORS
POISONING BY TETRACYCLIC ANTIDEPRESSANTS
POISONING BY TRICYCLIC ANTIDEPRESSANTS
POISONING BY OTHER ANTIDEPRESSANTS
POISONING BY PHENOTHIAZINE-BASED
TRANQUILIZERS
POISONING BY BUTYROPHENONE-BASED
TRANQUILIZERS
POISONING BY OTHER ANTIPSYCHOTICS
NEUROLEPTICS AND MAJOR TRANQUILIZERS
POISONING BY BENZODIAZEPINE-BASED
TRANQUILIZERS
POISONING BY OTHER TRANQUILIZERS
969.6
969.70
969.71
969.72
969.73
969.79
969.8
969.9
970.81
970.89
972.1
977.9
V15.81
V58.69
POISONING BY PSYCHODYSLEPTICS
(HALLUCINOGENS)
POISONING BY PSYCHOSTIMULANT,
UNSPECIFIED
POISONING BY CAFFEINE
POISONING BY AMPHETAMINES
POISONING BY METHYLPHENIDATE
POISONING BY OTHER PSYCHOSTIMULANTS
POISONING BY OTHER SPECIFIED
PSYCHOTROPIC AGENTS
POISONING BY UNSPECIFIED PSYCHOTROPIC
AGENT
POISONING BY COCAINE
POISONING BY OTHER CENTRAL NERVOUS
SYSTEM STIMULANTS
POISONING BY CARDIOTONIC GLYCOSIDES AND
DRUGS OF SIMILAR ACTION
POISONING BY UNSPECIFIED DRUG OR MEDICINAL
SUBSTANCE
PERSONAL HISTORY OF NONCOMPLIANCE WITH
MEDICAL TREATMENT PRESENTING HAZARDS TO
HEALTH
LONG-TERM (CURRENT) USE OF OTHER
MEDICATIONS
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
5/15/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Vitamin D: 25 Hydroxy
Data Source: https://www.novitas-solutions.com
CPT Code: 82306
LCD Description: The most common type of vitamin D deficiency is that of 25 OH vitamin D. It is expected that the medical record will justify the tests chosen for a
particular disease entity, that all available components of 25 OH vitamin D and other metabolite levels will not be performed routinely on every patient and that
supportive documentation for test choices will be available.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
010.00 - 018.96 PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED
EXAMINATION - UNSPECIFIED MILIARY TUBERCULOSIS
TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR
HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS
CONFIRMED BY OTHER METHODS (INOCULATION OF
ANIMALS)
135
SARCOIDOSIS
252.02
SECONDARY HYPERPARATHYROIDISM, NON-RENAL
268.0
RICKETS ACTIVE
268.2
OSTEOMALACIA UNSPECIFIED
268.9
UNSPECIFIED VITAMIN D DEFICIENCY
275.3
DISORDERS OF PHOSPHORUS METABOLISM
275.41
HYPOCALCEMIA
275.42
HYPERCALCEMIA
278.8
OTHER HYPERALIMENTATION
359.5
MYOPATHY IN ENDOCRINE DISEASES CLASSIFIED
ELSEWHERE
555.0 - 555.9
REGIONAL ENTERITIS OF SMALL INTESTINE REGIONAL ENTERITIS OF UNSPECIFIED SITE
556.0 - 556.9
ULCERATIVE (CHRONIC) ENTEROCOLITIS ULCERATIVE COLITIS UNSPECIFIED
571.2
ALCOHOLIC CIRRHOSIS OF LIVER
571.5
CIRRHOSIS OF LIVER WITHOUT ALCOHOL
571.6
BILIARY CIRRHOSIS
576.8
OTHER SPECIFIED DISORDERS OF BILIARY TRACT
579.0 - 579.9
CELIAC DISEASE - UNSPECIFIED INTESTINAL
MALABSORPTION
585.3
585.4
585.5
585.6
696.1
710.0
710.3
729.1
733.00 - 733.09
733.90
756.51
756.52
CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)
CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)
CHRONIC KIDNEY DISEASE, STAGE V
END STAGE RENAL DISEASE
OTHER PSORIASIS AND SIMILAR DISORDERS
SYSTEMIC LUPUS ERYTHEMATOSUS
DERMATOMYOSITIS
MYALGIA AND MYOSITIS UNSPECIFIED
OSTEOPOROSIS UNSPECIFIED – OTHER
OSTEOPOROSIS
DISORDER OF BONE AND CARTILAGE UNSPECIFIED
OSTEOGENESIS IMPERFECTA
OSTEOPETROSIS
According to Novitas Medicare, use V58.65 with 268.2 to describe the current
long term use of glucocorticoids and V58.69 with 268.2 describe long term use
of anticonvulsants and other medication known to lower Vitamin D levels.
Utilization Guidelines
Only one 25 OH vitamin D level will be reimbursed in any 24 hour period.
Assays of vitamin D levels for conditions other than ICD 9-CM codes 268.0268.9 will be limited to once a year.
Assays of the appropriate vitamin D levels for ICD-9 CM codes 268.0-268.9
will be limited to 4 per year, for the previously identified deficient form of
vitamin D.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE)
Vitamin D: 1,25 Dihydroxy
CPT Code: 82652
Data Source: https://www.novitas-solutions.com
LCD Description: The most common type of vitamin D deficiency is that of 25 OH vitamin D. A much smaller percentage of 1, 25 dihydroxy vitamin D deficiency exists;
mostly in those with renal disease. It is expected that the medical record will justify the tests chosen for a particular disease entity, that all available components of 25
OH vitamin D and other metabolite levels will not be performed routinely on every patient and that supportive documentation for test choices will be available to the
Contractor upon request.
ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book
should be used as a complete reference.
010.00 - 018.96 PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - UNSPECIFIED MILIARY
TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL
EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS)
135
SARCOIDOSIS
268.0
RICKETS ACTIVE
278.8
OTHER HYPERALIMENTATION
585.3
CHRONIC KIDNEY DISEASE, STAGE III (MODERATE)
585.4
CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE)
585.5
CHRONIC KIDNEY DISEASE, STAGE V
585.6
END STAGE RENAL DISEASE
756.51
OSTEOGENESIS IMPERFECTA
756.52
OSTEOPETROSIS
According to Novitas Medicare, use V58.65 with 268.2 to describe the current long term use of glucocorticoids and V58.69 with 268.2 describe long term use of
anticonvulsants and other medication known to lower Vitamin D levels.
Utilization Guidelines
Only one 1,25-OH vitamin D level will be reimbursed in a 24 hour period if medically necessary.
Assays of vitamin D levels for conditions other than ICD 9-CM codes 268.0-268.9 will be limited to once a year.
Assays of the appropriate vitamin D levels for ICD-9 CM codes 268.0-268.9 will be limited to 4 per year, for the previously identified deficient form of vitamin D.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“The cpt codes provided are based on ama guidelines and are for informational purposes only. Cpt coding is the sole responsibility of the billing party.
Please direct any questions regarding coding to the payer being billed.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
04/05/12
All third party marks - ® and ™ - are the property of their respective owners. © 2012 Quest Diagnostics Incorporated. All rights reserved