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REIMBURSEMENT POLICY

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Proprietary information of UnitedHealthcare Community and State. Copyright 2017 United Healthcare Services, Inc. 2018R7100A

Clinical Diagnostic Labs Policy

Policy Number

2018R7100A Annual Approval Date

3/8/2018 Approved By

Reimbursement Policy Oversight Committee

IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY

You are responsible for submission of accurate claims. This reimbursement policy is intended to ensure that you are reimbursed based on the code or codes that correctly describe the health care services provided. UnitedHealthcare Community Plan reimbursement policies uses Current Procedural Terminology (CPT

*), Centers for Medicare and Medicaid Services (CMS) or other coding guidelines.

References to CPT or other sources are for definitional purposes only and do not imply any right to reimbursement. This reimbursement policy applies to all health care services billed on CMS 1500 forms and, when specified, to those billed on UB04 forms. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design and other factors are considered in developing reimbursement policy. This information is intended to serve only as a general reference resource regarding UnitedHealthcare Community Plans reimbursement policy for the services described and is not intended to address every aspect of a reimbursement situation. Accordingly, UnitedHealthcare Community Plan may use reasonable discretion in interpreting and applying this policy to health care services provided in a particular case. Further, the policy does not address all issues related to reimbursement for health care services provided to UnitedHealthcare Community Plan enrollees. Other factors affecting reimbursement supplement, modify or, in some cases, supersede this policy. These factors include, but are not limited to: federal &/or state regulatory requirements, the

physician or other provider contracts, the enrollees benefit coverage documents, and/or other reimbursement, medical or drug policies. Finally, this policy may not be implemented exactly the same way on the different electronic claims processing systems used by UnitedHealthcare Community Plan due to programming or other constraints; however, UnitedHealthcare Community Plan strives to minimize these variations. UnitedHealthcare Community Plan may modify this reimbursement policy at any time by publishing a new version of the policy on this Website. However, the information presented in this policy is accurate and current as of the date of publication. (CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association).

Proprietary information of UnitedHealthcare Community and State

Copyright 2017 United Healthcare Services, Inc.

Application

This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products. This reimbursement policy applies to services reported using the 1500 Health Insurance Claim Form (a/k/a CMS-1500) or its electronic equivalent or its successor form. This policy applies to all products and all network and non-network physicians and other qualified health care professionals, including, but not limited to, non-network authorized and percent of charge contract physicians and other qualified health care professionals. Payment Policies for Medicare & Retirement, UnitedHealthcare Community Plan Medicare and Employer & Individual please use this link. Medicare & Retirement and UnitedHealthcare Community Plan Medicare Policies are listed under Medicare Advantage Reimbursement Policies. Employer & Individual are listed under Reimbursement Policies-Commercial.

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=ca174ccb4726b010VgnVCM100000c520720a____


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Policy

Overview

Based on the CMS National Coverage Determination (NCD) coding policy manual, services that are excluded from coverage include routine physical examinations and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury. CMS interprets these provisions to prohibit coverage of screening services, including laboratory tests furnished in the absence of signs, symptoms, or personal history of disease or injury. A national coverage policy for diagnostic laboratory test(s) is a document stating CMSs policy with respect to the circumstances under which the test(s) will be considered reasonable and necessary, and not screening.

Reimbursement Guidelines

This edit will allow clinical diagnostic lab procedure(s) when submitted with a diagnosis code found on the allowed diagnosis code list. When the clinical diagnostic lab procedure is billed as a routine screening service, as evidenced by the diagnosis code not found on the allowed diagnosis code list, the procedure code will deny.

Carcinoembryonic Antigen (CEA)

Carcinoembryonic antigen (CEA) is a protein polysaccharide found in some carcinomas. It is effective as a biochemical marker for monitoring the response of certain malignancies to therapy. UnitedHealthcare Community Plan reimburses for Carcinoembryonic antigen (CEA) (CPT codes 82378) when one of the diagnosis codes listed on a claim indicates a malignancy found on the list of approved diagnosis codes for this test.. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Alpha-fetoprotein (AFP)

Alpha-fetoprotein (AFP) is a polysaccharide found in some carcinomas. It is effective as a biochemical marker for monitoring the response of certain malignancies to therapy. AFP is useful for the diagnosis of hepatocellular carcinoma in high-risk patients (such as alcoholic cirrhosis, cirrhosis of viral etiology, hemochromatosis, and alpha 1-antitrypsin deficiency) and in separating patients with benign hepatocellular neoplasms or metastases from those with hepatocellular carcinoma and, as a non-specific tumor associated antigen, serves in marking germ cell neoplasms of the testis, ovary, retro peritoneum, and mediastinum. UnitedHealthcare Community Plan reimburses for Alpha-fetoprotein; serum (82105) when one of the diagnosis codes listed on a claim is found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Partial Thromboplastin Time (PTT)

Basic plasma coagulation function is readily assessed with a few simple laboratory tests: The Partial Thromboplastin Time (PTT), Prothrombin Time (PT), Thrombin Time (TT), or a quantitative fibrinogen determination. The PTT test is an in vitro laboratory test used to assess the intrinsic coagulation pathway and monitor heparin therapy. UnitedHealthcare Community Plan reimburses for Partial Thromboplastin Time (PTT) (CPT code 85730), when one billed with one of the approved diagnosis codes for this test.. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the and ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Prostate Specific Antigen (PSA)

Prostate Specific Antigen (PSA), a tumor marker for adenocarcinoma of the prostate, can predict residual tumor in the post-operative phase of prostate cancer. Three to 6 months after radical prostatectomy, PSA is reported to provide a sensitive indicator of persistent disease. Six months following introduction of


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antiandrogen therapy, PSA is reported of distinguishing patients with favorable response from those in whom limited response is anticipated. PSA when used in conjunction with other prostate cancer tests, such as digital rectal examination, may assist in the decision-making process for diagnosing prostate cancer. PSA also, serves as a marker in following the progress of most prostate tumors once a diagnosis has been established. This test is also an aid in the management of prostate cancer patients and in detecting metastatic or persistent disease in patients following treatment. UnitedHealthcare Community Plan reimburses for Prostate Specific Antigen (PSA) (CPT code 84153), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Urine Culture, Bacterial

A bacterial urine culture is a laboratory procedure performed on a urine specimen to establish the probable etiology of a presumed urinary tract infection. It is common practice to do a urinalysis prior to a urine culture. A urine culture may also be used as part of the evaluation and management of another related condition. The procedure includes aerobic agar-based isolation of bacteria or other cultivable organisms present, and quantitation of types present based on morphologic criteria. Isolates deemed significant may be subjected to additional identification and susceptibility procedures as requested by the ordering physician. The physicians request may be through clearly documented and communicated laboratory protocols. UnitedHealthcare Community Plan reimburses for Urine Culture, Bacterial (CPT codes 87086 and 87088), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Serum Iron Studies

Serum iron studies are useful in the evaluation of disorders of iron metabolism, particularly iron deficiency and iron excess. Iron studies are best performed when the patient is fasting in the morning and has abstained from medications that may influence iron balance. Iron deficiency is the most common cause of anemia. In young children on a milk diet, iron deficiency is often secondary to dietary deficiency. In adults, iron deficiency is usually the result of blood loss and is only occasionally secondary to dietary deficiency or malabsorption. Following major surgery the patient may have iron deficient erythropoietin for months or years if adequate iron replacement has not been given. High doses of supplemental iron may cause the serum iron to be elevated. Serum iron may also be altered in acute and chronic inflammatory and neoplastic conditions. Total Iron Binding Capacity (TIBC) is an indirect measure of transferring, a protein that binds and transports iron. TIBC quantifies transferring by the amount of iron that it can bind. TIBC and transferring are elevated in iron deficiency, and with oral contraceptive use, and during pregnancy. TIBC and transferring may be decreased in malabsorption syndromes or in those affected with chronic diseases. The percent saturation represents the ratio of iron to the TIBC. Assays for ferreting are also useful in assessing iron balance. Low concentrations are associated with iron deficiency and are highly specific. High concentrations are found in hemosiderosis (iron overload without associated tissue injury) and hemochromatosis (iron overload with associated tissue injury). In these conditions the iron is elevated, the TIBC and transferrin are within the reference range or low, and the percent saturation is elevated. Serum ferritin can be useful for both initiating and monitoring treatment for iron overload. Transferrin and ferritin belong to a group of serum proteins known as acute phase reactants, and are increased in response to stressful or inflammatory conditions and also can occur with infection and tissue injury due to surgery, trauma or necrosis. Ferritin and iron/TIBC (or transferrin) are affected by acute and


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chronic inflammatory conditions, and in patients with these disorders, tests of iron status may be difficult to interpret. UnitedHealthcare Community Plan reimburses for Serum Iron Studies (CPT codes 82728, 83540, 83550, and/or 84466), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Human Chorionic Gonadotropin (hCG)

Human Chorionic Gonadotropin (hCG) is useful for monitoring and diagnosis of germ cell neoplasms of the ovary, testis, mediastinum, retroperitoneum, and central nervous system. In addition, hCG is useful for monitoring pregnant patients with vaginal bleeding, hypertension and/or suspected fetal loss. UnitedHealthcare Community Plan reimburses for Human Chorionic Gonadotropin (hCG) (CPT code 84702), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Lipids Testing

Lipoproteins are a class of heterogeneous particles of varying sizes and densities containing lipid and protein. These lipoproteins include cholesterol esters and free cholesterol, triglycerides, phospholipids and A, C, and E apoproteins. Total cholesterol comprises all the cholesterol found in various lipoproteins. Factors that affect blood cholesterol levels include age, sex, body weight, diet, alcohol and tobacco use, exercise, genetic factors, family history, medications, menopausal status, the use of hormone replacement therapy, and chronic disorders such as hypothyroidism, obstructive liver disease, pancreatic disease (including diabetes), and kidney disease. In many individuals, an elevated blood cholesterol level constitutes an increased risk of developing coronary artery disease. Blood levels of total cholesterol and various fractions of cholesterol, especially low density lipoprotein cholesterol (LDL -C) and high density lipoprotein cholesterol (HDL-C) are useful in assessing and monitoring treatment for that risk in patients with cardiovascular and related diseases. Blood levels of the above cholesterol components including triglyceride have been separated into desirable, borderline and high-risk categories by the National Heart, Lung, and Blood Institute in their report in 1993. These categories form a useful basis for evaluation and treatment of patients with hyperlipidemia. Therapy to reduce these risk parameters includes diet, exercise and medication, and fat weight loss, which is particularly powerful when combined with diet and exercise. UnitedHealthcare Community Plan reimburses for Lipids Testing (CPT codes 80061, 83700, 83701, 83704, 83718, 83721, and 84478), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the and ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Thyroid Testing

Thyroid function studies are used to delineate the presence or absence of hormonal abnormalities of the thyroid and pituitary glands. These abnormalities may be either primary or secondary and often but not always accompany clinically defined signs and symptoms indicative of thyroid dysfunction. Laboratory evaluation of thyroid function has become more scientifically defined. Tests can be done with increased specificity, thereby reducing the number of tests needed to diagnose and follow treatment of most thyroid disease. Measurements of serum sensitive thyroid-stimulating hormone (TSH) levels, complemented by determination of thyroid hormone levels [free thyroxine (fT-4) or total thyroxine (T4) with Triiodothyronine (T3) uptake] are used for diagnosis and follow-up of patients with thyroid disorders.


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Additional tests may be necessary to evaluate certain complex diagnostic problems or on hospitalized patients, where many circumstances can skew tests results. When a test for total thyroxine (total T4 or T4 radioimmunoassay) or T3 uptake is performed, calculation of the free thyroxine index (FTI) is useful to correct for abnormal results for either total T4 or T3 uptake due to protein binding effects. UnitedHealthcare Community Plan reimburses for Thyroid Testing (CPT codes 84436, 84439, 84443, and 84479), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Prothrombin Time (PT)

Basic plasma coagulation function is readily assessed with a few simple laboratory tests: the Partial Thromboplastin Time (PTT), Prothrombin Time (PT), Thrombin Time (TT), or a quantitative fibrinogen determination. The PT test is one in-vitro laboratory test used to assess coagulation. While the PTT assesses the intrinsic limb of the coagulation system, the PT assesses the extrinsic or tissue factor dependent pathway. Both tests also evaluate the common coagulation pathway involving all the reactions that occur after the activation of factor X. Extrinsic pathway factors are produced in the liver and their production is dependent on adequate vitamin K activity. Deficiencies of factors may be related to decreased production or increased consumption of coagulation factors. The PT/INR is most commonly used to measure the effect of warfarin and regulate its dosing. Warfarin blocks the effect of vitamin K on hepatic production of extrinsic pathway factors. A PT is expressed in seconds and/or as an international normalized ratio (INR). The INR is the PT ratio that would result if the WHO reference thromboplastin was used in performing the test. Current medical information does not clarify the role of laboratory PT testing in patients who are self-monitoring. Therefore, the indications for testing apply regardless of whether or not the patient is also PT self-testing. UnitedHealthcare Community Plan reimburses for Prothrombin Time (CPT code 85610), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Tumor Antigen by Immunoassay CA 125

Immunoassay determinations of the serum levels of certain proteins or carbohydrates serve as tumor markers. When elevated, serum concentration of these markers may reflect tumor size and grade. This portion of the policy specifically addresses tumor antigen CA 125. These services are not covered for the evaluation of patients with signs or symptoms suggestive of malignancy. The service may be ordered at times necessary to assess either the presence of recurrent disease or the patients response to treatment with subsequent treatment cycles. UnitedHealthcare Community Plan reimburses for Tumor Antigen by Immunoassay CA 125 (CPT code 86304), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Tumor Antigen by Immunoassay CA 15-3/CA 27.29

Immunoassay determinations of the serum levels of certain proteins or carbohydrates serve as tumor markers. When elevated, serum concentration of markers may reflect tumor size & grade. This portion of the policy specifically addresses the following tumor antigens: CA 15-3 and CA 27.29.


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These services are not covered for the evaluation of patients with signs or symptoms suggestive of malignancy. The service may be ordered at times necessary to assess either the presence of recurrent disease or the patients response to treatment with subsequent treatment cycles. UnitedHealthcare Community Plan reimburses for Tumor Antigen by Immunoassay CA 15-3/CA 27.29 (CPT code 86300), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Tumor Antigen by Immunoassay CA 19-9

Immunoassay determinations of the serum levels of certain proteins or carbohydrates serve as tumor markers. When elevated, serum concentration of these markers may reflect tumor size and grade. This portion of the policy specifically addresses the following tumor antigen: CA19-9. These services are not covered for the evaluation of patients with signs or symptoms suggestive of malignancy. The service may be ordered at times necessary to assess either the presence of recurrent disease or the patients response to treatment with subsequent treatment cycles. UnitedHealthcare Community Plan reimburses for Tumor Antigen by Immunoassay CA 19-9 (CPT code 86301), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Gamma Glutamyl Transferase (GGT)

Gamma glutamyl transferase (GGT) is an intracellular enzyme that appears in blood following leakage from cells. Renal tubules, liver, and pancreas contain high amounts, although the measurement of GGT in serum is almost always used for assessment of Hepatobiliary function. Unlike other enzymes which are found in heart, skeletal muscle, and intestinal mucosa as well as liver, the appearance of an elevated level of GGT in serum is almost always the result of liver disease or injury. It is specifically useful to differentiate elevated alkaline phosphatase levels when the source of the alkaline phosphatase increase (bone, liver, or placenta) is unclear. The combination of high alkaline phosphatase and a normal GGT does not, however, rule out liver disease completely. As well as being a very specific marker of Hepatobiliary function, GGT is also a very sensitive marker for hepatocellular damage. Abnormal concentrations typically appear before elevations of other liver enzymes or biliuria are evident. Obstruction of the biliary tract, viral infection (e.g., hepatitis, mononucleosis), metastatic cancer, exposure to hepatotoxins (e.g., organic solvents, drugs, alcohol), and use of drugs that induce microsomal enzymes in the liver (e.g., cimetidine, barbiturates, phenytoin, and carbamazepine) all can cause a moderate to marked increase in GGT serum concentration. In addition, some drugs can cause or exacerbate liver dysfunction (e.g., atorvastatin, troglitazone, and others as noted in FDA Contraindications and Warnings.) GGT is useful for diagnosis of liver disease or injury, exclusion of hepatobiliary involvement related to other diseases, and patient management during the resolution of existing disease or following injury. UnitedHealthcare Community Plan reimburses for Gamma Glutamyl Transferase (CPT code 82977), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Hepatitis Panel/Acute Hepatitis Panel


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This panel consists of the following tests:

Hepatitis A antibody (HAAb), IgM antibody;

Hepatitis B core antibody (HBcAb), IgM antibody;

Hepatitis B surface antigen (HBsAg) and;

Hepatitis C antibody.

Hepatitis is an inflammation of the liver resulting from viruses, drugs, toxins, and other etiologies. Viral hepatitis can be due to one of at least five different viruses, designated hepatitis A, B, C, and E. Most cases are caused by hepatitis A virus (HAV), hepatitis B virus (HBV), or hepatitis C virus (HCV). HAV is the most common cause of hepatitis in children and adolescents in the United States. Prior exposure is indicated by a positive IgG anti-HAV. Acute HAV is diagnosed by IgM anti-HAV, which typically appears within four weeks of exposure, and which disappears within three months of its appearance. IgG anti-HAV is similar in the timing of its appearance, but it persists indefinitely. Its detection indicates prior effective immunization or recovery from infection. Although HAV is spread most commonly by fecal-oral exposure, standard immune globulin may be effective as a prophylaxis. HBV produces three separate antigens (surface, core, and e (envelope) antigens) when it infects the liver, although only hepatitis B surface antigen (HBsAg) is included as part of this panel. Following exposure, the body normally responds by producing antibodies to each of these antigens; one of which is included in this panel: hepatitis B surface antibody (HBsAb)-IgM antibody. HBsAg is the earlier marker, appearing in serum four to eight weeks after exposure, and typically disappearing within six months after its appearance. If HBsAg remains detectable for greater than six months, this indicates chronic HBV infection. HBcAb, in the form of both IgG and IgM antibodies, are next to appear in serum, typically becoming detectable two to three months following exposure. The IgM antibody gradually declines or disappears entirely one to two years following exposure, but the IgG usually remains detectable for life. Because HBsAg is present for a relatively short period and usually displays a low titer, a negative result does not exclude an HBV diagnosis. HBcAb, on the other hand, rises to a much higher titer and remains elevated for a longer period of time, but a positive result is not diagnostic of acute disease, since it may be the result of a prior infection. The last marker to appear in the course of a typical infection is HBsAb, which appears in serum four to six months following exposure to infected blood or body fluids; in the U.S., sexual transmission accounts for 30% to 60% of new cases of HBV infection. The diagnosis of acute HBV infection is best established by documentation of positive IgM antibody against the core antigen (HBcAb-IgM) and by identification of a positive hepatitis B surface antigen (HBsAg). The diagnosis of chronic HBV infection is established primarily by identifying a positive hepatitis B surface antigen (HBsAg) and demonstrating positive IgG antibody directed against the core antigen (HBcAb-IgG). Additional tests such as hepatitis B e antigen (HBeAg) and hepatitis B e antibody (HBeAb), the envelope antigen and antibody, are not included in the hepatitis panel, but may be of importance in assessing the infectivity of patients with HBV. Following completion of a HBV vaccination series, HBsAb alone may be used monthly for up to six months, or until a positive result is obtained, to verify an adequate antibody response. HCV is the most common cause of post-transfusion hepatitis; overall HCV is responsible for 15% to 20% of all cases of acute hepatitis, and is the most common cause of chronic liver disease. The test most commonly used to identify HCV measures HCV antibodies, which appear in blood two to four months after infection. False positive HCV results can occur. For example, a patient with a recent yeast infection may produce a false positive anti-HCV result. For this reason, at present positive results usually are confirmed by a more specific technique. Like HBV, HCV is spread exclusively through exposure to infected blood or body fluids. This panel of tests is used for differential diagnosis in a patient with symptoms of liver disease or injury. When the time of exposure or the stage of the disease is not known, a patient with continued symptoms of liver disease despite a completely negative hepatitis panel may need a repeat panel approximately two


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weeks to two months later to exclude the possibility of hepatitis. Once a diagnosis is established, specific tests can be used to monitor the course of the disease. UnitedHealthcare Community Plan reimburses for Hepatitis Panel/Acute Hepatits Panel (CPT code 80074), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Collagen Crosslinks

Collagen crosslinks, part of the matrix of bone upon which bone mineral is deposited, are biochemical markers the excretion of which provides a quantitative measurement of bone resorption. Elevated levels of urinary collagen crosslinks indicate elevated bone resorption. Elevated bone resorption contributes to age-related and postmenopausal loss of bone leading to osteoporosis and increased risk of fracture. The collagen crosslinks assay can be performed by immunoassay or by high performance liquid chromatography (HPLC). Collagen crosslink immunoassays measure the pyridinoline crosslinks and associated telopeptides in urine. Bone is constantly undergoing a metabolic process called turnover or remodeling. This includes a degradation process, bone resorption, mediated by the action of osteoclasts, and a building process, bone formation, mediated by the action of osteoblasts. Remodeling is required for the maintenance and overall health of bone and is tightly coupled; that is, resorption and formation must be in balance. In abnormal states of bone remodeling, when resorption exceeds formation, it results in a net loss of bone. The measurement of specific, bone-derived resorption products provides analytical data about the rate of bone resorption. Osteoporosis is a condition characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures of the hip, spine, and wrist. The term primary osteoporosis is applied where the causal factor in the disease is menopause or aging. The term secondary osteoporosis is applied where the causal factor is something other than menopause or aging, such as long-term administration of glucocorticosteroids, endocrine-related disorders (other than loss of estrogen due to menopause), and certain bone diseases such as cancer of the bone. With respect to quantifying bone resorption, collagen crosslink tests can provide adjunct diagnostic information in concert with bone mass measurements. Bone mass measurements and biochemical markers may have complementary roles to play in assessing effectiveness of osteoporosis treatment. Proper management of osteoporosis patients, who are on long-term therapeutic regimens, may include laboratory testing of biochemical markers of bone turnover, such as collagen crosslinks, that provide a profile of bone turnover responses within weeks of therapy. Changes in collagen crosslinks are determined following commencement of antiresorptive therapy. These can be measured over a shorter time interval when compared to bone mass density. If bone resorption is not elevated, repeat testing is not medically necessary. UnitedHealthcare Community Plan reimburses for Collagen Crosslinks Testing (CPT code 82523), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Digoxin Therapeutic Drug Assay

A digoxin therapeutic drug assay is useful for diagnosis and prevention of digoxin toxicity, and/or prevention for under dosage of digoxin. Digoxin levels may be performed to monitor drug levels of individuals receiving digoxin therapy because the margin of safety between side effects and toxicity is narrow or because the blood level may not be


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high enough to achieve the desired clinical effect. Clinical indications may include individuals on digoxin:

With symptoms, signs or electrocardiogram (ECG) suggestive of digoxin toxicity

Taking medications that influence absorption, bioavailability, distribution, and/or elimination of digoxin

With impaired renal, hepatic, gastrointestinal, or thyroid function

With pH and/or electrolyte abnormalities

With unstable cardiovascular status, including myocarditis

Requiring monitoring of patient compliance Clinical indications may include individuals:

Suspected of accidental or intended overdose

Who have an acceptable cardiac diagnosis (as listed) and for whom an accurate history of use of digoxin is unobtainable

The value of obtaining regular serum digoxin levels is uncertain, but it may be reasonable to check levels once yearly after a steady state is achieved. In addition, it may be reasonable to check the level if:

Heart failure status worsens

Renal function deteriorates

Additional medications are added that could affect the digoxin level

Signs or symptoms of toxicity develop Steady state will be reached in approximately 1 week in patients with normal renal function, although 2-3 weeks may be needed in patients with renal impairment. After changes in dosages or the addition of a medication that could affect the digoxin level, it is reasonable to check the digoxin level one week after the change or addition. Based on the clinical situation, in cases of digoxin toxicity, testing may need to be done more than once a week. Digoxin is indicated for the treatment of patients with heart failure due to systolic dysfunction and for reduction of the ventricular response in patients with atrial fibrillation or flutter. Digoxin may also be indicated to treat other supraventricular arrhythmias, particularly with heart failure. UnitedHealthcare Community Plan reimburses for Digoxin Therapeutic Drug Assay Testing (CPT code 80162), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

Glycated Hemoglobin/Glycated Protein

The management of diabetes mellitus requires regular determinations of blood glucose levels. Glycated hemoglobin/protein levels are used to assess long-term glucose control in diabetes. Alternative names for these tests include glycated or glycosylated hemoglobin or Hgb, hemoglobin glycated or glycosylated protein, and fructosamine. Glycated hemoglobin (equivalent to hemoglobin A1) refers to total glycosylated hemoglobin present in erythrocytes, usually determined by affinity or ion-exchange chromatographic methodology. Hemoglobin A1c refers to the major component of hemoglobin A1, usually determined by ion-exchange affinity chromatography, immunoassay or agar gel electrophoresis. Fructosamine or glycated protein refers to glycosylated protein present in a serum or plasma sample. Glycated protein refers to measurement of the component of the specific protein that is glycated usually by colorimetric method or affinity chromatography. Glycated hemoglobin in whole blood assesses glycemic control over a period of 4-8 weeks and appears


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to be the more appropriate test for monitoring a patient who is capable of maintaining long-term, stable control. Measurement may be medically necessary every 3 months to determine whether a patients metabolic control has been on average within the target range. More frequent assessments, every 1-2 months, may be appropriate in the patient whose diabetes regimen has been altered to improve control or in whom evidence is present that intercurrent events may have altered a previously satisfactory level of control (for example, post-major surgery or as a result of glucocorticoid therapy). Glycated protein in serum/plasma assesses glycemic control over a period of 1-2 weeks. It may be reasonable and necessary to monitor glycated protein monthly in pregnant diabetic women. Glycated hemoglobin/protein test results may be low, indicating significant, persistent hypoglycemia, in nesidioblastosis or insulinoma, conditions which are accompanied by inappropriate hyperinsulinemia. A below normal test value is helpful in establishing the patients hypoglycemic state in those conditions. UnitedHealthcare Community Plan reimburses for Glycated Hemoglobin/Glycated Protein Testing (CPT codes 82985 and 83036), when the claim indicates a code found on the list of approved diagnosis codes for this test. UnitedHealthcare Community Plan will not reimburse when the treatment rendered is without inclusion of one of the ICD-10-CM diagnostic codes being included on the claim accurately reflecting the member's condition.

State Exceptions

California California Medicaid uses state specific ICD-10 diagnosis codes lists for CPT codes 86304, 82728, and 84702 which are included in this policy.

Kansas Kansas is excluded from this policy based on state requirements.

Louisiana Louisiana Medicaid is excluded from the diagnosis requirement when CPT 84443 is billed for newborns age 0-28 days based on state requirements for newborn screenings.

Washington Washington Medicaid is excluded from the Thyroid Testing section of the policy based on state requirements.

Definitions

Screening The testing for disease or disease precursors so that early detection and treatment can be provided for those who test positive for the disease. Screening tests are performed when no specific sign, symptom, or diagnosis is present and the patient has not been exposed to a disease. The testing of a person to rule out or to confirm a suspected diagnosis because the patient has a sign and/or symptom is a diagnostic test, not a screening.

Questions and Answers

1

Q: What is a National Coverage Policy?

A: A national coverage policy for diagnostic laboratory test(s) is a document stating CMSs policy with respect to the circumstances under which the test(s) will be considered reasonable and necessary, and not screening, for Medicare purposes. Such a policy applies nationwide. A national coverage policy is neither a practice parameter nor a statement of the accepted standard of medical practice.

Codes


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CPT code section

82378 Carcinoembryonic antigen (CEA)

82105 Alpha-fetoprotein (AFP); serum

85730 Thromboplastin time, partial (PTT); plasma or whole blood

84153 Prostate Specific Antigen (PSA), total

87086 Culture, bacterial; quantitative, colony count, urine.

87088 Culture, bacterial; with isolation and presumptive identification of each isolates, urine.

82728 Ferritin

83540 Iron

83550 Iron Binding Capacity

84466 Transferrin

84702 Gonadotropin, chorionic (hCG); quantitative

80061 Lipid panel

83700 Lipoprotein, blood; electrophoretic separation and quantitation

83701 High resolution fractionation and quantitation of lipoprotein subclasses when performed (e.g., electrophoresis, ultracentrifugation)

83704 Lipoprotein, blood; quantitation of lipoprotein particle numbers and lipoprotein particle subclasses

83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol)

83721 LDL cholesterol

84478 Triglycerides

84436 Thyroxine; total

84439 Thyroxine; total free

84443 Thyroid stimulating hormone (TSH)

84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR)

85610 Prothrombin time (PT)

86304 Immunoassay for tumor antigen, quantitative; CA 125

86300 Immunoassay for tumor antigen, quantitative; CA 15-3

86301 Immunoassay for tumor antigen, quantitative; CA 19-9

82977 Glutamyltransferase, gamma (GGT)

80074 Acute hepatitis panel

82523 Collagen crosslinks, any method

80162 Digoxin; total

82985 Glycated protein


CMS-1500


83036 Hemoglobin; glycosylated (A1C)

Attachments: Please right-click on the icon to open the file

UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 82378 (CEA) (Effective 01/1/18)

List of ICD-10 codes for which CPT code 82378 will be reimbursed.

UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 82105 (AFP) (Effective 01/1/18)


UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 85730 (PTT) (Effective 01/1/18)


UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 84153 (PSA) (Effective 01/1/18)


UnitedHealthcare Community Plan ICD-10 Codes approved with CPT codes 87086 and 87088 (Urine Culture, Bacterial) (Effective 01/1/18)

List of ICD-10 codes for which CPT codes 87086 and 87088 will be reimbursed.

UnitedHealthcare Community Plan ICD-10 Codes approved with CPT codes 82728, 83540, 83550, and/or 84466 (Serum Iron) (Effective 01/1/18)

List of ICD-10 codes for which CPT codes 82728, 83540, 83550, and/or 84466 will be reimbursed.

List of ICD-10 codes for which CPT code 82728 will be

2018A

UnitedHealthc

are Community

Plan ICD-10

Codes

approved with

CPT code

82378 (CEA)

(Effective

01/1/18)

C15.3

C15.4

C15.5

C15.8

C15.9

C16.0

C16.1

C16.2

C16.3

C16.4

C16.5

C16.6

C16.8

C16.9

C17.0

C17.2

C17.3

C17.8

C17.9

C18.0

C18.1

C18.2

C18.3

C18.4

C18.5

C18.6

C18.7

C18.8

C18.9

C19

C20

C21.0

C21.1

C21.2

C21.8

C25.0

C25.1

C25.2

C25.3

C25.4

C25.7

C25.8

C25.9

C26.0

C33

C34.00

C34.01

C34.02

C34.10

C34.11

C34.12

C34.2

C34.30

C34.31

C34.32

C34.80

C34.81

C34.82

C34.90

C34.91

C34.92

C50.011

C50.012

C50.019

C50.021

C50.022

C50.029

C50.111

C50.112

C50.119

C50.121

C50.122

C50.129

C50.211

C50.212

C50.219

C50.221

C50.222

C50.229

C50.311

C50.312

C50.319

C50.321

C50.322

C50.329

C50.411

C50.412

C50.419

C50.421

C50.422

C50.429

C50.511

C50.512

C50.519

C50.521

C50.522

C50.529

C50.611

C50.612

C50.619

C50.621

C50.622

C50.629

C50.811

C50.812

C50.819

C50.821

C50.822

C50.829

C50.911

C50.912

C50.919

C50.921

C50.922

C50.929

C56.1

C56.2

C56.9

C7A.00

C7A.010

C7A.011

C7A.012

C7A.019

C7A.020

C7A.021

C7A.022

C7A.023

C7A.024

C7A.025

C7A.026

C7A.029

C7A.090

C7A.091

C7A.092

C7A.093

C7A.094

C7A.095

C7A.096

C7A.098

C7B.00

C7B.01

C7B.02

C7B.03

C7B.04

C7B.09

C7B.1

C7B.8

C78.00

C78.01

C78.02

C78.4

C78.5

D01.0

D01.1

D01.2

D01.40

D01.49

D01.7

D01.9

D37.1

D37.2

D37.3

D37.4

D37.5

G89.3

R70.1

R77.0

R77.1

R77.2

R77.8

R77.9

R78.89

R78.9

R79.89

R97.0

R97.8

Z08

Z09

Z85.00

Z85.038

Z85.048

Z85.118

Z85.3

Z85.43

avinc11File Attachment2018A UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 82378 (CEA) .pdf

2018A

UnitedHealthcar

e Community

Plan ICD-10

Codes approved

with CPT code

82105 (AFP)

(Effective

01/1/18)

A52.74

B18.0

B18.1

B18.2

B66.1

B66.3

C22.0

C22.1

C22.2

C22.3

C22.4

C22.7

C22.8

C22.9

C38.1

C38.2

C38.3

C38.8

C56.1

C56.2

C56.9

C62.00

C62.01

C62.02

C62.10

C62.11

C62.12

C62.90

C62.91

C62.92

C78.1

C78.7

C79.60

C79.61

C79.62

C79.82

C7A.00

C7A.090

C7A.091

C7A.092

C7A.093

C7A.094

C7A.095

C7A.096

C7A.098

C7B.00

C7B.01

C7B.02

C7B.03

C7B.04

C7B.09

C7B.1

C7B.8

D13.4

D13.5

D37.6

D64.0

D64.1

D64.2

D64.3

D81.810

D84.1

E78.2

E83.00

E83.01

E83.09

E83.10

E83.110

E83.111

E83.118

E83.119

E83.19

E84.19

E84.9

E88.01

G89.3

I25.84

I74.01

I74.09

I74.10

I74.19

J98.59

K70.2

K70.30

K70.31

K73.0

K73.1

K73.2

K73.8

K73.9

K74.0

K74.60

K74.69

K75.4

K76.81

N44.1

N44.2

N44.8

N50.3

N50.811

N50.812

N50.819

N50.82

N50.89

N53.12

N53.8

N53.9

*Q53.111

*Q53.112

*Q53.13

*Q53.211

*Q53.212

*Q53.23

*R39.83

*R39.84

R91.1

R91.8

R93.1

R93.2

R93.5

R93.8

R97.8

Z17.0

Z17.1

Z85.05

Z85.43

Z85.47

avinc11File Attachment2018A UnitedHealthcare Community Plan ICD-10 Codes approved with CPT code 82105 (AFP) .pdf

2018A

UnitedHealthca

re Community

Plan ICD-10

Codes approved

with CPT code

85730 (PTT)

(Effective

01/1/18)

A01.00

A01.01

A01.02

A01.03

A01.04

A01.05

A01.09

A01.1

A01.2

A01.3

A01.4

A02.0

A02.1

A02.20

A02.21

A02.22

A02.23

A02.24

A02.25

A02.29

A02.8

A02.9

A41.9

A91

A92.0

A95.0

A95.1

A95.9

A96.0

A96.1

A96.8

A96.9

A98.0

A98.1

A98.2

A98.5

A98.8

A99

B15.0

B15.9

B16.0

B16.1

B16.2

B16.9

B17.0

B17.10

B17.11

B17.2

B17.8

B17.9

B18.0

B18.1

B18.2

B18.8

B18.9

B19.0

B19.10

B19.11

B19.20

B19.21

B19.9

B20

B25.1

B25.2

B27.00

B27.01

B27.02

B27.09

B27.10

B27.11

B27.12

B27.19

B27.80

B27.81

B27.82

B27.89

B27.90

B27.91

B27.92

B27.99

B52.0

B65.0

B66.1

B66.3

B75

C22.0

C22.1

C22.2

C22.3

C22.4

C22.7

C22.8

C22.9

C78.7

C88.0

C88.8

C94.40

C94.41

C94.42

C94.6

D45

D46.0

D46.1

D46.20

D46.21

D46.22

D46.4

D46.9

D46.A

D46.B

D46.C

D46.Z

D47.1

D47.2

D47.3

D47.9

D47.Z1

D47.Z2

D47.Z9

D49.9

D62

D65

D66

D67

D68.0

D68.1

D68.2

D68.311

D68.312

D68.318

D68.32

D68.4

D68.51

D68.52

D68.59

D68.61

D68.62

D68.8

D68.9

D69.0

D69.1

D69.2

D69.3

D69.41

D69.42

D69.49

D69.51

D69.59

D69.6

D69.8

D69.9

D75.1

D78.01

D78.02

D78.21

D78.22

D78.31

D78.32

D86.0

D86.1

D86.2

D86.3

D86.81

D86.82

D86.83

D86.84

D86.85

D86.86

D86.87

D86.89

D86.9

D89.0

D89.1

D89.2

E07.89

E08.21

E08.22

E08.29

E08.52

E08.65

E09.21

E09.22

E09.29

E09.52

E10.21

E10.22

E10.29

E10.52

E10.65

E11.21

E11.22

E11.29

E11.52

E11.65

E13.21

E13.22

E13.29

E13.52

E20.1

E36.01

E36.02

E56.1

E80.0

E80.1

E80.20

E80.21

E80.29

E83.00

E83.01

E83.09

E83.10

E83.110

E83.111

E83.118

E83.119

E83.19

E83.30

E83.31

E83.32

E83.39

E83.40

E83.41

E83.42

E83.49

E83.50

E83.51

E83.52

E83.59

E83.81

E83.89

E83.9

E85.0

E85.1

E85.2

E85.3

E85.4

E85.81

E85.9

E88.09

E89.810

E89.811

E89.820

E89.821

G08

G45.3

G45.9

G97.31

G97.32

G97.51

G97.52

G97.61

G97.62

H02.89

H05.231

H05.232

H05.233

H05.239

H11.30

H11.31

H11.32

H11.33

H31.301

H31.302

H31.303

H31.309

H31.311

H31.312

H31.313

H31.319

H31.321

H31.322

H31.323

H31.329

H31.411

H31.412

H31.413

H31.419

H34.00

H34.01

H34.02

H34.03

H34.10

H34.11

H34.12

H34.13

H34.211

H34.212

H34.213

H34.219

H34.231

H34.232

H34.233

H34.239

H34.8110

H34.8111

H34.8112

H34.8120

H34.8121

H34.8122

H34.8130

H34.8131

H34.8132

H34.8190

H34.8191

H34.8192

H34.821

H34.822

H34.823

H34.829

H34.8310

H34.8311

H34.8312

H34.8320

H34.8321

H34.8322

H34.8330

H34.8331

H34.8332

H34.8390

H34.8391

H34.8392

H34.9

H35.60

H35.61

H35.62

H35.63

H35.731

H35.732

H35.733

H35.739

H43.10

H43.11

H43.12

H43.13

H44.2E1

H44.2E2

H44.2E3

H44.811

H44.812

H44.813

H44.819

H47.021

H47.022

H47.023

H47.029

H53.9

H59.111

H59.112

H59.113

H59.119

H59.121

H59.122

H59.123

H59.129

H59.311

H59.312

H59.313

H59.319

H59.321

H59.322

H59.323

H59.329

H59.331

H59.332

H59.333

H59.339

H59.341

H59.342

H59.343

H59.349

H61.121

H61.122

H61.123

H61.129

H95.21

H95.22

H95.41

H95.42

H95.51

H95.52

I12.0

I13.11

I16.0

I16.1

I16.9

I21.01

I21.02

I21.09

I21.11

I21.19

I21.21

I21.29

I21.3

I21.4

I21.9

I21.A1

I21.A9

I22.0

I22.1

I22.2

I22.8

I22.9

I23.0

I23.3

I23.6

I23.7

I23.8

*I27.83

I31.2

I48.0

I48.1

I48.2

I48.91

I49.9

I50.20

I50.21

I50.22

I50.23

I50.30

I50.31

I50.32

I50.33

I50.40

I50.41

I50.42

I50.43

I50.9

I60.00

I60.01

I60.02

I60.10

I60.11

I60.12

I60.2

I60.30

I60.31

I60.32

I60.4

I60.50

I60.51

I60.52

I60.6

I60.7

I60.8

I60.9

I61.0

I61.1

I61.2

I61.3

I61.4

I61.5

I61.6

I61.8

I61.9

I62.00

I62.01

I62.02

I62.03

I62.1

I62.9

I63.00

I63.011

I63.012

I63.013

I63.019

I63.02

I63.031

I63.032

I63.033

I63.039

I63.09

I63.10

I63.111

I63.112

I63.113

I63.119

I63.12

I63.131

I63.132

I63.133

I63.139

I63.19

I63.20

I63.211

I63.212

I63.213

I63.219

I63.22

I63.231

I63.232

I63.233

I63.239

I63.29

I63.30

I63.311

I63.312

I63.313

I63.319

I63.321

I63.322

I63.323

I63.329

I63.331

I63.332

I63.333

I63.339

I63.341

I63.342

I63.343

I63.349

I63.39

I63.40

I63.411

I63.412

I63.413

I63.419

I63.421

I63.422

I63.423

I63.429

I63.431

I63.432

I63.433

I63.439

I63.441

I63.442

I63.443

I63.449

I63.49

I63.50

I63.511

I63.512

I63.513

I63.519

I63.521

I63.522

I63.523

I63.529

I63.531

I63.532

I63.533

I63.539

I63.541

I63.542

I63.543

I63.549

I63.59

I63.6

I63.8

I63.9

I65.01

I65.02

I65.03

I65.09

I65.1

I65.21

I65.22

I65.23

I65.29

I65.8

I65.9

I66.01

I66.02

I66.03

I66.09

I66.11

I66.12

I66.13

I66.19

I66.21

I66.22

I66.23

I66.29

I66.3

I66.8

I66.9

I67.841

I67.848

I70.361

I70.362

I70.363

I70.368

I70.369

I70.461

I70.462

I70.463

I70.468

I70.469

I70.561

I70.562

I70.563

I70.568

I70.569

I70.661

I70.662

I70.663

I70.668

I70.669

I70.761

I70.762

I70.763

I70.768

I70.769

I73.01

I74.01

I74.09

I74.10

I74.11

I74.19

I74.2

I74.3

I74.4

I74.5

I74.8

I74.9

I77.2

I78.0

I80.00

I80.01

I80.02

I80.03

I80.10

I80.11

I80.12

I80.13

I80.201

I80.202

I80.203

I80.209

I80.211

I80.212

I80.213

I80.219

I80.221

I80.222

I80.223

I80.229

I80.231

I80.232

I80.233

I80.239

I80.291

I80.292

I80.293

I80.299

I80.3

I80.8

I80.9

I82.0

I82.1

I82.210

I82.211

I82.220

I82.221

I82.290

I82.291

I82.3

I82.401

I82.402

I82.403

I82.409

I82.411

I82.412

I82.413

I82.419

I82.421

I82.422

I82.423

I82.429

I82.431

I82.432

I82.433

I82.439

I82.441

I82.442

I82.443

I82.449

I82.491

I82.492

I82.493

I82.499

I82.4Y1

I82.4Y2

I82.4Y3

I82.4Y9

I82.4Z1

I82.4Z2

I82.4Z3

I82.4Z9

I82.501

I82.502

I82.503

I82.509

I82.511

I82.512

I82.513

I82.519

I82.521

I82.522

I82.523

I82.529

I82.531

I82.532

I82.533

I82.539

I82.541

I82.542

I82.543

I82.549

I82.591

I82.592

I82.593

I82.599

I82.5Y1

I82.5Y2

I82.5Y3

I82.5Y9

I82.5Z1

I82.5Z2

I82.5Z3

I82.5Z9

I82.601

I82.602

I82.603

I82.609

I82.611

I82.612

I82.613

I82.619

I82.621

I82.622

I82.623

I82.629

I82.701

I82.702

I82.703

I82.709

I82.711

I82.712

I82.713

I82.719

I82.721

I82.722

I82.723

I82.729

I82.811

I82.812

I82.813

I82.819

I82.890

I82.891

I82.90

I82.91

I82.A11

I82.A12

I82.A13

I82.A19

I82.A21

I82.A22

I82.A23

I82.A29

I82.B11

I82.B12

I82.B13

I82.B19

I82.B21

I82.B22

I82.B23

I82.B29

I82.C11

I82.C12

I82.C13

I82.C19

I82.C21

I82.C22

I82.C23

I82.C29

I85.00

I85.01

I86.4

I86.8

I87.8

I96

I97.410

I97.411

I97.418

I97.42

I97.610

I97.611

I97.618

I97.620

I97.621

I97.630

I97.631

I97.638

I97.810

I97.811

I97.820

I97.821

I99.8

J95.61

J95.62

J95.830

J95.831

J95.860

J95.861

K22.6

K22.8

K25.0

K25.1

K25.2

K25.3

K25.4

K25.5

K25.6

K25.7

K25.9

K26.0

K26.1

K26.2

K26.3

K26.4

K26.5

K26.6

K26.7

K26.9

K27.0

K27.1

K27.2

K27.3

K27.4

K27.5

K27.6

K27.7

K27.9

K28.0

K28.1

K28.2

K28.3

K28.4

K28.5

K28.6

K28.7

K28.9

K29.00

K29.01

K29.20

K29.21

K29.30

K29.31

K29.40

K29.41

K29.50

K29.51

K29.60

K29.61

K29.70

K29.71

K29.80

K29.81

K29.90

K29.91

K31.811

K31.82

K51.00

K51.011

K51.012

K51.013

K51.014

K51.018

K51.019

K51.20

K51.211

K51.212

K51.213

K51.214

K51.218

K51.219

K51.30

K51.311

K51.312

K51.313

K51.314

K51.318

K51.319

K51.40

K51.411

K51.412

K51.413

K51.414

K51.418

K51.419

K51.50

K51.511

K51.512

K51.513

K51.514

K51.518

K51.519

K51.80

K51.811

K51.812

K51.813

K51.814

K51.818

K51.819

K51.90

K51.911

K51.912

K51.913

K51.914

K51.918

K51.919

K52.81

K55.011

K55.012

K55.019

K55.021

K55.022

K55.029

K55.031

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K55.039

K55.041

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K55.049

K55.051

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K55.059

K55.061

K55.062

K55.069

K55.1

K55.30

K55.31

K55.32

K55.33

K55.8

K55.9

K57.01

K57.11

K57.13

K57.21

K57.31

K57.33

K57.41

K57.51

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K57.81

K57.91

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K70.0

K70.10

K70.11

K70.2

K70.30

K70.31

K70.40

K70.41

K70.9

K71.0

K71.10

K71.11

K71.2

K71.3

K71.4

K71.50

K71.51

K71.6

K71.7

K71.8

K71.9

K72.00

K72.01

K72.10

K72.11

K72.90

K72.91

K73.0

K73.1

K73.2

K73.8

K73.9

K74.0

K74.1

K74.2

K74.3

K74.4

K74.5

K74.60

K74.69

K75.0

K75.1

K75.2

K75.3

K75.4

K75.81

K75.89

K75.9

K76.0

K76.1

K76.2

K76.3

K76.4

K76.5

K76.6

K76.7

K76.81

K76.89

K76.9

K77

K80.30

K80.31

K80.32

K80.33

K80.34

K80.35

K80.36

K80.37

K83.0

K83.1

K83.2

K83.3

K83.4

K83.5

K83.8

K83.9

K85.00

K85.01

K85.02

K85.10

K85.11

K85.12

K85.20

K85.21

K85.22

K85.30

K85.31

K85.32

K85.80

K85.81

K85.82

K85.90

K85.91

K85.92

K87

K90.0

K90.1

K90.2

K90.3

K90.41

K90.49

K90.89

K90.9

K91.2

K91.5

K91.61

K91.62

K91.840

K91.841

K91.870

K91.871

K92.0

K92.1

K92.2

L76.01

L76.02

L76.21

L76.22

L76.31

L76.32

M02.20

M02.211

M02.212

M02.219

M02.221

M02.222

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M02.231

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M02.239

M02.241

M02.242

M02.249

M02.251

M02.252

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M02.261

M02.262

M02.269

M02.271

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M02.279

M02.28

M02.29

M25.00

M25.011

M25.012

M25.019

M25.021

M25.022

M25.029

M25.031

M25.032

M25.039

M25.041

M25.042

M25.049

M25.051

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M25.059

M25.061

M25.062

M25.069

M25.071

M25.072

M25.073

M25.074

M25.075

M25.076

M25.08

M31.1

M32.0

M32.10

M32.11

M32.12

M32.13

M32.14

M32.15

M32.19

M32.8

M32.9

M36.2

M36.3

M36.4

M48.50XA

M48.51XA

M48.52XA

M48.53XA

M48.54XA

M48.55XA

M48.56XA

M48.57XA

M48.58XA

M79.601

M79.602

M79.603

M79.604

M79.605

M79.606

M79.609

M79.621

M79.622

M79.629

M79.631

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M79.669

M79.671

M79.672

M79.673

M79.674

M79.675

M79.676

M79.89

M80.00XA

M80.011A

M80.012A

M80.019A

M80.021A

M80.022A

M80.029A

M80.031A

M80.032A

M80.039A

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M97.02XA

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M97.12XA

M97.21XA

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M97.31XA

M97.32XA

N02.0

N02.1

N02.2

N02.3

N02.4

N02.5

N02.6

N02.7

N02.8

N02.9

N04.0

N04.1

N04.2

N04.3

N04.4

N04.5

N04.6

N04.7

N04.8

N04.9

N05.9

N06.9

N07.9

N08

N15.9

N17.0

N17.1

N17.2

N17.8

N17.9

N18.4

N18.5

N18.6

N18.9

N19

N28.0

N28.82

N28.89

N32.89

N33

N50.1

N64.89

N83.7

N85.7

N88.8

N89.8

N90.89

N92.1

N92.4

N93.0

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N95.0

N99.510

N99.511

N99.512

N99.518

N99.61

N99.62

N99.820

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N99.840

N99.841

O02.1

O03.0

O03.1

O03.2

O03.30

O03.31

O03.32

O03.33

O03.34

O03.35

O03.36

O03.37

O03.38

O03.39

O03.4

O03.5

O03.6

O03.7

O03.80

O03.81

O03.82

O03.83

O03.84

O03.85

O03.86

O03.87

O03.88

O03.89

O03.9

O04.6

O07.1

O08.1

O08.2

O10.011

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O10.013

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O10.02

O10.03

O10.111

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O10.12

O10.13

O10.211

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O10.311

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O10.32

O10.33

O10.411

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O10.43

O10.911

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O10.913

O10.919

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O11.1

O11.2

O11.3

O11.9

O12.04

O12.05

O12.14

O12.15

O12.24

O12.25

O13.1

O13.2

O13.3

O13.4

O13.5

O13.9

O14.00

O14.02

O14.03

O14.04

O14.05

O14.10

O14.12

O14.13

O14.14

O14.15

O14.20

O14.22

O14.23

O14.24

O14.25

O14.90

O14.92

O14.93

O14.94

O14.95

O15.00

O15.02

O15.03

O15.1

O15.2

O15.9

O16.1

O16.2

O16.3

O16.4

O16.5

O16.9

O20.0

O20.8

O20.9

O22.20

O22.21

O22.22

O22.23

O22.30

O22.31

O22.32

O22.33

O22.50

O22.51

O22.52

O22.53

O22.91

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O24.415

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O41.1011

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O41.1019

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O41.1210

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O41.1215

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O41.1222

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O41.1224

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O41.1235

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O41.1410

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O41.1419

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O41.1421

O41.1422

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O41.1424

O41.1425

O41.1429

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O41.1433

O41.1434

O41.1435

O41.1439

O41.1490

O41.1491

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O41.1499

O43.011

O43.012

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O43.212

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O43.231

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O43.233

O44.00

O44.01

O44.02

O44.03

O44.10

O44.11

O44.12

O44.13

O44.20

O44.21

O44.22

O44.23

O44.30

O44.31

O44.32

O44.33

O44.40

O44.41

O44.42

O44.43

O44.50

O44.51

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O44.53

O45.001

O45.002

O45.003

O45.009

O45.011

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O45.021

O45.022

O45.023

O45.029

O45.091

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O45.099

O45.8X1

O45.8X2

O45.8X3

O45.8X9

O45.90

O45.91

O45.92

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O46.001

O46.002

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O46.009

O46.011

O46.012

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O46.019

O46.021

O46.022

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O46.029

O46.091

O46.092

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O46.8X1

O46.8X2

O46.8X3

O46.8X9

O46.90

O46.91

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O67.0

O67.8

O67.9

O72.0

O72.1

O72.2

O72.3

O86.0

O87.0

O87.1

O87.3

O88.011

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O88.02

O88.03

O88.111

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O88.811

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O88.819

O88.82

O88.83

O90.2

O99.111

O99.112

O99.113

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O99.12

O99.13

P02.1

P05.9

P10.0

P10.1

P10.2

P10.3

P10.4

P10.8

P10.9

P11.0

P11.1

P11.2

P11.9

P12.2

P15.0

P15.1

P15.2

P15.3

P15.4

P15.5

P15.6

P15.8

P26.0

P26.1

P26.8

P26.9

P50.0

P50.1

P50.2

P50.3

P50.4

P50.5

P50.8

P50.9

P51.0

P51.8

P51.9

P52.0

P52.1

P52.21

P52.22

P52.3

P52.4

P52.5

P52.6

P52.8

P52.9

P53

P54.0

P54.1

P54.2

P54.3

P54.4

P54.5

P54.6

P54.8

P54.9

P57.8

P57.9

P58.0

P58.1

P58.2

P58.3

P58.41

P58.42

P58.5

P58.8

P58.9

P59.0

P59.1

P59.20

P59.29

P59.3

P59.8

P59.9

P60

P61.0

P61.1

P61.2

P61.3

P61.4

P61.5

P61.6

P61.8

P61.9

R04.0

R04.1

R04.2

R04.81

R04.89

R04.9

R06.02

R07.82

R07.89

R07.9

R10.0

R10.10

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R10.12

R10.13

R10.2

R10.30

R10.31

R10.32

R10.33

R10.83

R10.84

R10.9

R17

R23.3

R29.700

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R29.702

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R29.704

R29.705

R29.706

R29.707

R29.708

R29.709

R29.710

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R29.736

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R31.1

R31.21

R31.29

R31.9

R40.2410

R40.2411

R40.2412

R40.2413

R40.2414

R40.2420

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R40.2430

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R40.2434

R40.2440

R40.2441

R40.2442

R40.2443

R40.2444

R55

R57.9

R79.1

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S00.10XA

S00.11XA

S00.12XA

S00.33XA

S00.431A

S00.432A

S00.439A

S00.531A

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S06.897A

S06.898A

S06.899A

S06.9X0A

S06.9X1A

S06.9X2A

S06.9X3A

S06.9X4A

S06.9X5A

S06.9X6A

S06.9X7A

S06.9X8A

S06.9X9A

S07.0XXA

S07.1XXA

S07.8XXA

S07.9XXA

S09.0XXA

S10.0XXA

S10.83XA

S10.93XA

S12.000A

S12.000B

S12.001A

S12.001B

S12.01XA

S12.01XB

S12.02XA

S12.02XB

S12.030A

S12.030B

S12.031A

S12.031B

S12.040A

S12.040B

S12.041A

S12.041B

S12.090A

S12.090B

S12.091A

S12.091B

S12.100A

S12.100B

S12.101A

S12.101B

S12.110A

S12.110B

S12.111A

S12.111B

S12.112A

S12.112B

S12.120A

S12.120B

S12.121A

S12.121B

S12.130A

S12.130B

S12.131A

S12.131B

S12.14XA

S12.14XB

S12.150A

S12.150B

S12.151A

S12.151B

S12.190A

S12.190B

S12.191A

S12.191B

S12.200A

S12.200B

S12.201A

S12.201B

S12.230A

S12.230B

S12.231A

S12.231B

S12.24XA

S12.24XB

S12.250A

S12.250B

S12.251A

S12.251B

S12.290A

S12.290B

S12.291A

S12.291B

S12.300A

S12.300B

S12.301A

S12.301B

S12.330A

S12.330B

S12.331A

S12.331B

S12.34XA

S12.34XB

S12.350A

S12.350B

S12.351A

S12.351B

S12.390A

S12.390B

S12.391A

S12.391B

S12.400A

S12.400B

S12.401A

S12.401B

S12.430A

S12.430B

S12.431A

S12.431B

S12.44XA

S12.44XB

S12.450A

S12.450B

S12.451A

S12.451B

S12.490A

S12.490B

S12.491A

S12.491B

S12.500A

S12.500B

S12.501A

S12.501B

S12.530A

S12.530B

S12.531A

S12.531B

S12.54XA

S12.54XB

S12.550A

S12.550B

S12.551A

S12.551B

S12.590A

S12.590B

S12.591A

S12.591B

S12.600A

S12.600B

S12.601A

S12.601B

S12.630A

S12.630B

S12.631A

S12.631B

S12.64XA

S12.64XB

S12.650A

S12.650B

S12.651A

S12.651B

S12.690A

S12.690B

S12.691A

S12.691B

S12.9XXA

S14.101A

S14.102A

S14.103A

S14.104A

S14.105A

S14.106A

S14.107A

S14.109A

S14.111A

S14.112A

S14.113A

S14.114A

S14.115A

S14.116A

S14.117A

S14.121A

S14.122A

S14.123A

S14.124A

S14.125A

S14.126A

S14.127A

S14.131A

S14.132A

S14.133A

S14.134A

S14.135A

S14.136A

S14.137A

S14.151A

S14.152A

S14.153A

S14.154A

S14.155A

S14.156A

S14.157A

S15.001A

S15.002A

S15.009A

S15.011A

S15.012A

S15.019A

S15.021A

S15.022A

S15.029A

S15.091A

S15.092A

S15.099A

S15.101A

S15.102A

S15.109A

S15.111A

S15.112A

S15.119A

S15.121A

S15.122A

S15.129A

S15.191A

S15.192A

S15.199A

S15.201A

S15.202A

S15.209A

S15.211A

S15.212A

S15.219A

S15.221A

S15.222A

S15.229A

S15.291A

S15.292A

S15.299A

S15.301A

S15.302A

S15.309A

S15.311A

S15.312A

S15.319A

S15.321A

S15.322A

S15.329A

S15.391A

S15.392A

S15.399A

S15.8XXA

S15.9XXA

S17.0XXA

S17.8XXA

S17.9XXA

S20.00XA

S20.01XA

S20.02XA

S20.20XA

S20.211A

S20.212A

S20.219A

S20.221A

S20.222A

S20.229A

S21.301A

S21.302A

S21.309A

S21.311A

S21.312A

S21.319A

S21.321A

S21.322A

S21.329A

S21.331A

S21.332A

S21.339A

S21.341A

S21.342A

S21.349A

S21.351A

S21.352A

S21.359A

S21.401A

S21.402A

S21.409A

S21.411A

S21.412A

S21.419A

S21.421A

S21.422A

S21.429A

S21.431A

S21.432A

S21.439A

S21.441A

S21.442A

S21.449A

S21.451A

S21.452A

S21.459A

S22.000A

S22.000B

S22.001A

S22.001B

S22.002A

S22.002B

S22.008A

S22.008B

S22.009A

S22.009B

S22.010A

S22.010B

S22.011A

S22.011B

S22.012A

S22.012B

S22.018A

S22.018B

S22.019A

S22.019B

S22.020A

S22.020B

S22.021A

S22.021B

S22.022A

S22.022B

S22.028A

S22.028B

S22.029A

S22.029B

S22.030A

S22.030B

S22.031A

S22.031B

S22.032A

S22.032B

S22.038A

S22.038B

S22.039A

S22.039B

S22.040A

S22.040B

S22.041A

S22.041B

S22.042A

S22.042B

S22.048A

S22.048B

S22.049A

S22.049B

S22.050A

S22.050B

S22.051A

S22.051B

S22.052A

S22.052B

S22.058A

S22.058B

S22.059A

S22.059B

S22.060A

S22.060B

S22.061A

S22.061B

S22.062A

S22.062B

S22.068A

S22.068B

S22.069A

S22.069B

S22.070A

S22.070B

S22.071A

S22.071B

S22.072A

S22.072B

S22.078A

S22.078B

S22.079A

S22.079B

S22.080A

S22.080B

S22.081A

S22.081B

S22.082A

S22.082B

S22.088A

S22.088B

S22.089A

S22.089B

S22.20XA

S22.20XB

S22.31XA

S22.31XB

S22.32XA

S22.32XB

S22.39XA

S22.39XB

S22.41XA

S22.41XB

S22.42XA

S22.42XB

S22.43XA

S22.43XB

S22.49XA

S22.49XB

S22.9XXA

S22.9XXB

S24.101A

S24.102A

S24.103A

S24.104A

S24.109A

S24.111A

S24.112A

S24.113A

S24.114A

S24.131A

S24.132A

S24.133A

S24.134A

S24.151A

S24.152A

S24.153A

S24.154A

S25.00XA

S25.01XA

S25.02XA

S25.09XA

S25.101A

S25.102A

S25.109A

S25.111A

S25.112A

S25.119A

S25.121A

S25.122A

S25.129A

S25.191A

S25.192A

S25.199A

S25.20XA

S25.21XA

S25.22XA

S25.29XA

S25.301A

S25.302A

S25.309A

S25.311A

S25.312A

S25.319A

S25.321A

S25.322A

S25.329A

S25.391A

S25.392A

S25.399A

S25.401A

S25.402A

S25.409A

S25.411A

S25.412A

S25.419A

S25.421A

S25.422A

S25.429A

S25.491A

S25.492A

S25.499A

S25.501A

S25.502A

S25.509A

S25.511A

S25.512A

S25.519A

S25.591A

S25.592A

S25.599A

S25.801A

S25.802A

S25.809A

S25.811A

S25.812A

S25.819A

S25.891A

S25.892A

S25.899A

S25.90XA

S25.91XA

S25.99XA

S26.00XA

S26.01XA

S26.020A

S26.021A

S26.022A

S26.09XA

S26.10XA

S26.11XA

S26.12XA

S26.19XA

S26.90XA

S26.91XA

S26.92XA

S26.99XA

S27.0XXA

S27.1XXA

S27.2XXA

S27.301A

S27.302A

S27.309A

S27.311A

S27.312A

S27.319A

S27.321A

S27.322A

S27.329A

S27.331A

S27.332A

S27.339A

S27.391A

S27.392A

S27.399A

S27.401A

S27.402A

S27.409A

S27.411A

S27.412A

S27.419A

S27.421A

S27.422A

S27.429A

S27.431A

S27.432A

S27.439A

S27.491A

S27.492A

S27.499A

S27.50XA

S27.51XA

S27.52XA

S27.53XA

S27.59XA

S27.60XA

S27.63XA

S27.69XA

S27.802A

S27.803A

S27.808A

S27.809A

S27.812A

S27.813A

S27.818A

S27.819A

S27.892A

S27.893A

S27.898A

S27.899A

S27.9XXA

S28.0XXA

S30.0XXA

S30.1XXA

S30.201A

S30.202A

S30.21XA

S30.22XA

S30.23XA

S30.3XXA

S31.001A

S31.011A

S31.021A

S31.031A

S31.041A

S31.051A

S31.600A

S31.601A

S31.602A

S31.603A

S31.604A

S31.605A

S31.609A

S31.610A

S31.611A

S31.612A

S31.613A

S31.614A

S31.615A

S31.619A

S31.620A

S31.621A

S31.622A

S31.623A

S31.624A

S31.625A

S31.629A

S31.630A

S31.631A

S31.632A

S31.633A

S31.634A

S31.635A

S31.639A

S31.640A

S31.641A

S31.642A

S31.643A

S31.644A

S31.645A

S31.649A

S31.650A

S31.651A

S31.652A

S31.653A

S31.654A

S31.655A

S31.659A

S32.000A

S32.000B

S32.001A

S32.001B

S32.002A

S32.002B

S32.008A

S32.008B

S32.009A

S32.009B

S32.010A

S32.010B

S32.011A

S32.011B

S32.012A

S32.012B

S32.018A

S32.018B

S32.019A

S32.019B

S32.020A

S32.020B

S32.021A

S32.021B

S32.022A

S32.022B

S32.028A

S32.028B

S32.029A

S32.029B

S32.030A

S32.030B

S32.031A

S32.031B

S32.032A

S32.032B

S32.038A

S32.038B

S32.039A

S32.039B

S32.040A

S32.040B

S32.041A

S32.041B

S32.042A

S32.042B

S32.048A

S32.048B

S32.049A

S32.049B

S32.050A

S32.050B

S32.051A

S32.051B

S32.052A

S32.052B

S32.058A

S32.058B

S32.059A

S32.059B

S32.10XA

S32.10XB

S32.110A

S32.110B

S32.111A

S32.111B

S32.112A

S32.112B

S32.119A

S32.119B

S32.120A

S32.120B

S32.121A

S32.121B

S32.122A

S32.122B

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