medicare national and local coverage … acute myocardial infarction of inferolateral wall episode...

Last Updated: 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

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 7/1/2015

Medicare National and Local Coverage Determination Policy – AL,GA,NC,SC,TN

12/01/2013

• Click policy below for Local MLCP Policy ToolDocument contains the below Medicare LocalLimited Coverage Policies for lab testing performed inAL,GA,NC,SC,TN

• B-type Natriuretic Peptide (BNP) Testing• C-Reactive Protein; High Sensitivity (hsCRP)• CYP2C19, CYP2D6, CYP2C9, and VKORC1

Genetic Testing• Molecular Pathology Procedures for Human

Leukocyte Antigen (HLA) Typing• Qualitative Drug Testing• Vitamin D Assay Testing / Vitamin D 1, 25

Dihydroxy• Vitamin D Assay Testing / Vitamin D 25 Hydroxy

• Click here for National MLCP Policies ToolDocument contains information on National MedicareLimited 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

http://corpwebcms.qdx.com/dms/Documents/mlcp/ICD9-MLCP/Tool1.pdf%23page=1

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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.” 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

Medicare Local Coverage Determination Policy B-type Natriuretic Peptide (BNP) Testing CPT Code: 83880 LCD ID Number L30046

Data Source: http://cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDid=30046

LCD Description:. B-Natriuretic Peptide is synthesized , stored, and released primarily by the ventricular myocardium in response to volume expansion and pressure overload, which are hemodynamic parameters in Congestive Heart Failure (CHF). Serum BNP, when used in conjunction with other clinical information, will be considered reasonable and necessary for the following: Establishing the diagnosis of CHF in acutely ill patients presenting with dyspnea and Predicting the long term risk or cardiac events or death across the spectrum of acute coronary syndromes when measured in the first few days after an acute coronary event. ICD-9-CM Codes that Support Medical Necessity The B-Natriuretic Peptide test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s) provided.

402.01 Malignant hypertensive heart disease with heart failure

402.11 Benign hypertensive heart disease with heart failure

402.91 Unspecified hypertensive heart disease with heart failure

404.01 Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified

404.03 Hypertensive heart and chronic kidney disease, malignant, with heart failure and with chronic kidney disease stage V or end stage renal disease

404.11 Hypertensive heart and chronic kidney disease, benign, with heart failure and with chronic kidney disease stage I through stage IV, or unspecified

404.13 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 – 410.92 Acute myocardial infarction of anterolateral wall episode of care unspecified - Acute myocardial infarction of unspecified site subsequent episode of care

411.1 Intermediate coronary syndrome

428.0 Congestive heart failure unspecified

428.1 Left heart failure

428.20 Unspecified systolic heart failure

428.21 Acute systolic heart failure

428.22 Chronic systolic heart failure

428.23 Acute on chronic systolic heart failure

428.30 Unspecified diastolic heart failure

428.31 Acute diastolic heart failure

428.32 Chronic diastolic heart failure

428.33 Acute on chronic diastolic heart failure

428.40 Unspecified combined systolic and diastolic heart failure

428.41 Acute combined systolic and diastolic heart failure

428.42 Chronic combined systolic and diastolic heart failure

428.43 Acute on chronic combined systolic and diastolic heart failure

428.9 Heart failure unspecified

786.00 Respiratory abnormality unspecified

786.02 Orthopnea

786.05 Shortness of breath

786.06 Tachypnea

786.07 Wheezing

786.09 Respiratory abnormality other

1/04/12

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Medicare Local Coverage Determination Policy C-Reactive Protein; High Sensitivity (hsCRP) CPT Code: 86141 LCD ID Number L30591

Indications: CRP (C-Reactive Protein) is an inflammatory marker that has been studied to determine its role in screening, detecting and monitoring of many disease processes. Cardiovascular disease has been shown to involve an inflammatory process that may be correlated to various inflammatory markers including CRP, specifically hsCRP (high sensitivity).

Limitations: There is no current literature to support the use of hsCRP in the monitoring of coronary artery disease. Also, hsCRP is not covered as a screening tool. Therefore, hsCRP (CPT 86141) is a noncovered service.

ICD-9 CM Codes that Support Medical Necessity: None

Data Source: http://cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=30591

Important Note: Please prepare an Advance Beneficiary Notice of Non-coverage Form (ABN) and ask the patient to read and sign it when ordering a C-Reactive Protein; High Sensitivity (CRP) on Medicare Patients.

10/03/11

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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-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.” 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. © 2015 Quest Diagnostics Incorporated. All rights reserved

Medicare Local Coverage Determination Policy CYP2C19, CYP2D6, CYP2C9, and VKORC1 Genetic Testing (1 of 3)

Data Source: http://www.cms.gov

CPT Codes (Group 1) : 81225 CYP2C19 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 19) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *8, *17) CPT Codes (Group 2) : 81226 CYP2D6 (CYTOCHROME P450, FAMILY 2, SUBFAMILY D, POLYPEPTIDE 6) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) CPT Codes (Group 3) : 81227 CYP2C9 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 9) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *5, *6) 81355 VKORC1 (VITAMIN K EPOXIDE REDUCTASE COMPLEX, SUBUNIT 1) (EG, WARFARIN METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, -1639/3673) LCD ID Number: L35306 ICD-9-CM Codes that Support Medical Necessity The correct use of an ICD-9-CM code listed in the “ICD-9 Codes that Support Medical Necessity” section does not guarantee coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this LCD.

3/01/2015

Group 1 Codes: 410.00 ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED 410.10 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED 410.20 ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED 410.30 ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED 410.40 ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED 410.50 ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED 410.60 TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED 410.70 SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED 410.80 ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED 410.90 ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED 411.0 POSTMYOCARDIAL INFARCTION SYNDROME 411.1 INTERMEDIATE CORONARY SYNDROME 411.81 ACUTE CORONARY OCCLUSION WITHOUT MYOCARDIAL INFARCTION 411.89 OTHER ACUTE AND SUBACUTE FORMS OF ISCHEMIC HEART DISEASE OTHER 413.0 ANGINA DECUBITUS 413.1 PRINZMETAL ANGINA 413.9 OTHER AND UNSPECIFIED ANGINA PECTORIS

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Medicare Local Coverage Determination Policy Data Source: http://www.cms.gov

CYP2C19, CYP2D6, CYP2C9, and VKORC1 GeneticTesting (2 of 3)

Group 2 Codes: 296.30 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE 296.31 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MILD DEGREE 296.32 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MODERATE DEGREE 296.33 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC BEHAVIOR 296.34 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR 296.35 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN PARTIAL OR UNSPECIFIED REMISSION 296.36 MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN FULL REMISSION 296.50 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, UNSPECIFIED 296.51 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MILD 296.52 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MODERATE 296.53 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR 296.54 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR 296.55 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, IN PARTIAL OR UNSPECIFIED REMISSION 296.56 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, IN FULL REMISSION 296.60 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, UNSPECIFIED 296.61 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MILD 296.62 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MODERATE 296.63 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR 296.64 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR 296.65 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN PARTIAL OR UNSPECIFIED REMISSION 296.66 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN FULL REMISSION 311 DEPRESSIVE DISORDER NOT ELSEWHERE CLASSIFIED 333.4 HUNTINGTON'S CHOREA

3/01/2015

CPT Codes (Group 1) : 81225 CYP2C19 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 19) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *8, *17) CPT Codes (Group 2) : 81226 CYP2D6 (CYTOCHROME P450, FAMILY 2, SUBFAMILY D, POLYPEPTIDE 6) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) CPT Codes (Group 3) : 81227 CYP2C9 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 9) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *5, *6) 81355 VKORC1 (VITAMIN K EPOXIDE REDUCTASE COMPLEX, SUBUNIT 1) (EG, WARFARIN METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, -1639/3673) LCD ID Number: L35306 ICD-9-CM Codes that Support Medical Necessity The correct use of an ICD-9-CM code listed in the “ICD Codes that Support Medical Necessity” section does not guarantee coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this LCD.

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Medicare Local Coverage Determination Policy Data Source: http://www.cms.gov

CYP2C19, CYP2D6, CYP2C9, and VKORC1 GeneticTesting (3 of 3)

3/01/2015

CPT Codes (Group 1) : 81225 CYP2C19 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 19) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *8, *17) CPT Codes (Group 2) : 81226 CYP2D6 (CYTOCHROME P450, FAMILY 2, SUBFAMILY D, POLYPEPTIDE 6) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) CPT Codes (Group 3) : 81227 CYP2C9 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 9) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *5, *6) 81355 VKORC1 (VITAMIN K EPOXIDE REDUCTASE COMPLEX, SUBUNIT 1) (EG, WARFARIN METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, -1639/3673) LCD ID Number: L35306 ICD-9-CM Codes that Support Medical Necessity The correct use of an ICD-9-CM code listed in the “ICD Codes that Support Medical Necessity” section does not guarantee coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this LCD. Group 3 Codes: XX000 Not Applicable

Covered Indications Effective August 3, 2009, the Centers for Medicare & Medicaid Services (CMS) believes that the available evidence supports that coverage with evidence development (CED) under §1862(a)(1)(E) of the Social Security Act (the Act) is appropriate for pharmacogenomic testing of CYP2C9 or VKORC1 alleles to predict warfarin responsiveness by any method, and is therefore covered only when provided to Medicare beneficiaries who are candidates for anticoagulation therapy with warfarin who: •Have not been previously tested for CYP2C9 or VKORC1 alleles; and •Have received fewer than five days of warfarin in the anticoagulation regimen for which the testing is ordered; and •Are enrolled in a prospective, randomized, controlled clinical study when that study meets the following standards. Non-covered Indications All other coverage for genetic testing for the CYP2C9 gene is considered investigational at this time. There is currently no proven clinical utility related to any medication, including but not limited to: Celecoxib, Fluorbiprofen, Flovoxamine Non-covered Indications There is insufficient evidence to demonstrate that genetic testing for the VKORC1 gene improves clinical outcomes. Consequently, genetic testing for the VKORC1 gene outside of the specified covered indications is considered investigational.

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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.” 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. © 2014 Quest Diagnostics Incorporated. All rights reserved

Medicare Local Coverage Determination Policy Molecular Pathology Procedures for Human Leukocyte Antigen (HLA) Typing


CPT Codes (Group 1) : 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383 CPT Codes (Group 2) : 81374 for HLA-B*27 Testing CPT Codes (Group 4) : 81381 for HLA-B*5701 Testing CPT Codes (Group 3) : 81381 for HLA-B*1502 Testing CPT Codes (Group 5) : 81376, 81377, 81382, 81383 LCD ID Number: L34511 ICD-9-CM Codes that Support Medical Necessity Molecular Pathology Procedures for HLA Testing is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s).

4/01/2014

Group 1 CPT Codes 81370-81383 Group 1 Codes: 996.80 - 996.89 COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN V42.0 - V42.9 KIDNEY REPLACED BY TRANSPLANT - UNSPECIFIED ORGAN OR TISSUE REPLACED BY TRANSPLANT

Group 2 Paragraph: CPT Code 81374 for HLA-B*27 Testing Group 2 Codes: 720.0 ANKYLOSING SPONDYLITIS

Group 3 Paragraph: CPT Code 81381 for HLA-B*1502 Testing Group 3 Codes: 780.31 - 780.39 FEBRILE CONVULSIONS (SIMPLE), UNSPECIFIED - OTHER CONVULSIONS V58.69* LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS Group 3 Medical Necessity ICD-9 Codes Asterisk Explanation: ** V58.69 must also be reported with each primary diagnosis code. This is a dual diagnosis requirement.

Group 4 Paragraph: CPT Code 81381 for HLA-B*5701 Testing Group 4 Codes: 042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE V08 ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION STATUS

Group 5 Paragraph: CPT Codes 81376, 81377, 81382, 81383 Group 5 Codes: 579.0 CELIAC DISEASE

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Medicare Local Coverage Determination Policy Qualitative Drug Testing


CPT Codes (Group 1) : G0431, G0434, G6058 CPT Codes (Group 2) : The following CPT codes are Non-Covered by Medicare: 80100 and 80101 LCD ID Number: L33635 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. ICD-9-CM Codes that Support Medical Necessity (Group 1 codes) Qualitative Drug Testing is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s).

04/09/2015

276.2 Acidosis 295.00 – 295.30 Simple type schizophrenia unspecified state – paranoid type schizophrenia unspecified state 304.01 Opioid type dependence continuous use 304.90 Unspecified drug dependence unspecified use 305.90 Other mixed or unspecified drug abuse unspecified use 345.10 – 345.11 Generalized convulsive epilepsy without intractable epilepsy – generalized convulsive epilepsy with intractable epilepsy 345.3 Grand mal status epileptic 345.90 – 345.91 Epilepsy unspecified without intractable epilepsy – epilepsy unspecified with intractable epilepsy 426.10 – 426.13 Atrioventricular block unspecified – other second degree atrioventricular block 426.82 Long QT syndrome 427.0 – 427.1 Paroxysmal supraventricular tachycardia – paroxysmal ventricular tachycardia 780.01 Coma 780.09 Alteration of consciousness other 780.1 Hallucinations 780.39 Other convulsions 963.0 Poisoning by antiallergic and antiemetic drugs

965.00 – 965.09 Poisoning by opium (alkaloids) unspecified – poisoning by other opiates and related narcotics 965.1 Poisoning by salicylates 965.4 Poisoning by aromatic analgesics not elsewhere classified 965.5 Poisoning by pyrazole derivatives 965.61 Poisoning by propionic acid derivatives 966.1 Poisoning by hydantoin derivatives 967.0 – 967.9 Poisoning by barbiturates – Poisoning by unspecified sedative or hypnotic 969.00 – 969.9 Poisoning by antidepressant, unspecified – poisoning by unspecified psychotropic agent 972.1 Poisoning by cardiotonic glycosides and drugs of similar action 977.9 Poisoning by unspecified drug or medicinal substance V15.81 Personal history of noncompliance with medical treatment presenting hazards to health V58.69* Long-term (current) use of other medications V71.09* observation of other suspected mental condition Group 1 Medical Necessity ICD-9 Codes Asterisk Explanation: *V58.69*: Use for the monitoring of patients on methadone maintenance and chronic pain patients with opioid dependence, suspected of abusing other illicit drugs. V71.09*: Use for monitoring of patient compliance in a drug treatment program as the primary diagnosis and the specific drug dependence diagnosis as the secondary diagnosis.

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Medicare Local Coverage Determination Policy Vitamin D Assay Testing / Vitamin D 1, 25 Dihydroxy


CPT Code: 82652 LCD ID Number: DL30905 LCD Limitations: • Screening for vitamin D deficiency is not covered. • The various component sources of vitamin D (such as stored D or diet derived D) are included in one (1) 25 OH vitamin D assay or one (1) 1, 25 (OH) 2 vitamin D assay. • Once a beneficiary has been shown to be vitamin D deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Monitoring therapeutic replacement would not be expected to exceed 2 assays per year. Once therapeutic range has been reached, testing would not be expected to exceed one (1) assay per year. • Repeated testing with both assays would not be expected.

ICD-9-CM Codes that Support Medical Necessity: Vitamin D, 1,25 Dihydroxy is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s).

275.42 Hypercalcemia 585.3 – 585.6 Chronic kidney disease, stage III (moderate) – End stage renal disease 588.0 Renal Osteodystrophy

10/03/11

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Medicare Local Coverage Determination Policy Vitamin D Assay Testing / Vitamin D, 25 Hydroxy


CPT Code: 82306 LCD ID Number: DL30905 LCD Limitations: • Screening for vitamin D deficiency is not covered. • The various component sources of vitamin D (such as stored D or diet derived D) are included in one (1) 25 OH vitamin D assay or one (1) 1, 25 (OH) 2 vitamin D assay. • Once a beneficiary has been shown to be vitamin D deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Monitoring therapeutic replacement would not be expected to exceed 2 assays per year. Once therapeutic range has been reached, testing would not be expected to exceed one (1) assay per year. • Repeated testing with both assays would not be expected. ICD-9-CM Codes that Support Medical Necessity: Vitamin D, 25 Hydroxy is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record must support the medical necessity for the test(s).

042 Human immunodeficiency virus (HIV) disease 252.00 Hyperparathyroidism, unspecified 252.01 Primary hyperparathyroidism 252.02 Secondary hyperparathyroidism, non-renal 252.08 Other hyperparathyroidism 252.1 Hypoparathyroidism 263.0 Malnutrition of moderate degree 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 277.00 – 277.09 Cystic fibrosis without meconium ileus - Cystic fibrosis with other manifestations

345.00 – 345.91 Generalized nonconvulsive epilepsy without intractable epilepsy - Epilepsy unspecified with intractable epilepsy

555.0 – 558.9 Regional enteritis of small intestine - Other and unspecified noninfectious gastroenteritis and colitis

579.0 – 579.9 Celiac disease – Unspecified intestional malabsorption 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 588.81 Secondary hyperparathyoidism (of renal organ) 733.00 – 733.09 Osteoporosis unspecified – Other osteoporosis 733.90 Disorder of bone and cartilage unspecified V45.86 Bariatric surgery status V58.65 Long-term (current) use of steroids

10/03/11