Download ICD-10 - Quest Diagnostics

Medicare National and Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
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.
• Click here for National MLCP Policies Tool
Document contains information on National Medicare
Limited Coverage Policies
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Alpha-Fetoprotein
Blood Counts
Blood Glucose Testing
Carcinoembryonic Antigen
Collagen Crosslinks - Any Method
Digoxin Therapeutic Drug Assay
Fecal Occult Blood
Gamma Glutamyl Transferase
Glycated Hemoglobin - Glycated Protein
Hepatitis Panel/Acute Hepatitis Panel
Human Chorionic Gonadotropin
Human Immunodeficiency Virus (HIV) Testing
(Diagnosis)
Human Immunodeficiency Virus (HIV) Testing
(Prognosis Including Monitoring)
Lipids Testing
Partial Thromboplastin Time (PTT)
Prostate Specific Antigen
Prothrombin Time (PT)
Serum Iron Studies
Thyroid Testing
Tumor Antigen by Immunoassay CA 15-3 CA 27.29
Tumor Antigen by Immunoassay CA 19-9
Tumor Antigen by Immunoassay CA-125
Urine Culture, Bacterial
• Click here for Local MLCP Policies Tool
Document contains information on Medicare Local
Limited Coverage Policies for lab testing performed in
CT, MA, ME, NH, RI, VT
• B-type Natriuretic Peptide (BNP) Testing
• Combined Ovarian Cancer Biomarker Tests
• Genomic Sequence Analysis Panels in the Treatment of Non-Small
Cell Lung Cancer
• Heavy Metal Testing
• Molecular Pathology Procedures
• Non-covered Services
• RAST Type Tests
• Urine Drug Testing
• Vitamin D Assay Testing
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. © 2016 Quest Diagnostics Incorporated. All rights reserved
Last Updated:
10/01/16
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
B-type Natriuretic Peptide (BNP) Testing
Data Source: Local Coverage Determination (LCD):
CPT Code: 83880
B-type Natriuretic Peptide (BNP) Testing (L33573)
LCD Description: B-type natriuretic peptide (BNP) is a cardiac neurohormone produced mainly in the left ventricle. It is secreted in response to ventricular volume expansion
and pressure overload, factors often found in congestive heart failure (CHF). Used in conjunction with other clinical information, rapid measurement of BNP is useful in
establishing or excluding the diagnosis and assessing the severity of CHF in patients with acute dyspnea so that appropriate and timely treatment can be initiated.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
Table 1: ICD-10-CM codes that support medical necessity when billed in
either an office or outpatient setting.
Group 1 Codes:
E85.0 Non-neuropathic heredofamilial amyloidosis
E85.1 Neuropathic heredofamilial amyloidosis
E85.2 Heredofamilial amyloidosis, unspecified
E85.3 Secondary systemic amyloidosis
E85.4 Organ-limited amyloidosis
E85.8 Other amyloidosis
E85.9 Amyloidosis, unspecified
I11.0 Hypertensive heart disease with heart failure
I13.0 Hypertensive heart and chronic kidney disease with heart failure and
stage 1 through stage 4 chronic kidney disease, or unspecified chronic
kidney disease
I13.2 Hypertensive heart and chronic kidney disease with heart failure and with
stage 5 chronic kidney disease, or end stage renal disease
I50.1 Left ventricular failure
I50.20 Unspecified systolic (congestive) heart failure
I50.21 Acute systolic (congestive) heart failure
I50.22 Chronic systolic (congestive) heart failure
I50.23 Acute on chronic systolic (congestive) heart failure
I50.30 Unspecified diastolic (congestive) heart failure
I50.31 Acute diastolic (congestive) heart failure
I50.32 Chronic diastolic (congestive) heart failure
I50.33 Acute on chronic diastolic (congestive) heart failure
I50.40 Unspecified combined systolic (congestive) and diastolic (congestive)
heart failure
I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart
failure
I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart
failure
I50.43
I50.9
J44.0
J44.1
J45.901
J98.01
R06.00
R06.01
R06.02
R06.09
R06.2
R06.82
R06.89
R06.9
Acute on chronic combined systolic (congestive) and diastolic (congestive)
heart failure
Heart failure, unspecified
Chronic obstructive pulmonary disease with acute lower respiratory infection
Chronic obstructive pulmonary disease with (acute) exacerbation
Unspecified asthma with (acute) exacerbation
Acute bronchospasm
Dyspnea, unspecified
Orthopnea
Shortness of breath
Other forms of dyspnea
Wheezing
Tachypnea, not elsewhere classified
Other abnormalities of breathing
Unspecified abnormalities of breathing
Utilization Guidelines: The use of BNP for monitoring CHF is not covered.
Limitations: BNP measurements must be analyzed in conjunction with standard diagnostic tests,
medical history and clinical findings. The efficacy of BNP measurement as a stand-alone test has
not yet been established. Clinicians should be aware that certain conditions such as ischemia,
infarction and renal insufficiency, may cause elevation of circulating BNP concentration and
require alterations of the interpretation of BNP results.
Additional investigation is required to further define the diagnostic value of plasma BNP in
monitoring the efficiency of treatment for CHF and in tailoring the therapy for heart failure.
Therefore, BNP measurements for monitoring and management of CHF are not a covered service.
Although a correlation between serum BNP levels and the clinical severity of HF has been shown
in broad populations, “it cannot be assumed that BNP levels can be used effectively as targets for
adjustment of therapy in individual patients. [T]he BNP measurement has not been clearly shown
to supplement careful clinical assessment.” (Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA
2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: A
Report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines, pgs. 14-15)
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-10-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.
Last Updated:
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.
07/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Combined Ovarian Cancer Biomarker Tests
Data Source: Local Coverage Determination for
CPT Code: 81500, 81503, 84999
Combined Ovarian Cancer Biomarker Tests (L33588)
LCD Description: OVA-1 is an ovarian cancer blood test that is reported to detect ovarian cancer in a pelvic mass. It is an aggregation of five biomarkers, beta 2microglobulin, apolipoprotein A-1, CA-125, transferrin and transthyretin. The Risk of Ovarian Malignancy Algorithm (ROMA™), is another test which combines the same
traditionally proven tumor marker, CA-125, with HE-4, human epidydimus protein 4, a relatively new protein marker produced by the over-expression of the gene WFDC2,
and associated with epithelial ovarian neoplasia.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s
medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM
book should be used as a complete reference.
CPT/HCPCS Codes
Group 1 Paragraph: N/A
Group 1 Codes:
81500 ONCOLOGY (OVARIAN), BIOCHEMICAL ASSAYS OF TWO PROTEINS (CA-125 AND HE4), UTILIZING SERUM, WITH MENOPAUSAL STATUS,
ALGORITHM REPORTED AS A RISK SCORE
81503 ONCOLOGY (OVARIAN), BIOCHEMICAL ASSAYS OF FIVE PROTEINS (CA-125, APOLIPOPROTEIN A1, BETA-2 MICROGLOBULIN, TRANSFERRIN,
AND PRE-ALBUMIN), UTILIZING SERUM, ALGORITHM REPORTED AS A RISK SCORE
84999 UNLISTED CHEMISTRY PROCEDURE
ICD-10 Codes that Support Medical Necessity
Group 1 Paragraph: N/A
ICD-10 Codes that DO NOT Support Medical Necessity N/A
Indications and Limitations:
Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.
At the present time, National Government Services does not find either the OVA-1 or the ROMA ™ test to be of proven efficacy in the diagnosis or treatment of ovarian
cancer. National Government Services will only allow coverage of CA-125 as allowed by the national coverage decision.
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Genomic Sequence Analysis Panels in the Treatment
Data Source: Genomic Sequence Analysis Panels
of Non-Small Cell Lung Cancer
CPT Code: 81445
in the Treatment of Non-Small Cell Lung Cancer
(L36376)
LCD Description: Most lung cancers are epithelial in origin, with squamous cell carcinomas, adenocarcinomas, and small cell carcinomas being the predominant histologic
types. The first two, squamous and adenocarcinomas, have been traditionally grouped as non-small cell lung cancer (NSCLC). Surgery remains the cornerstone of treatment
for early stage NSCLC of either type, however treatment of advanced stage disease is based primarily on drugs. Distinctive response patterns to specific therapeutic drugs
have been demonstrated over the past 12 years, necessitating the distinction between squamous cell and adenocarcinoma morphology. Consequently the most recent WHO
guidelines advocate sub-classification of all NSCLC in to a more specific subtype whenever possible. This is typically accomplished by histologic evaluation with support from
specific immunohistochemical studies, which are particularly useful in the evaluation of small biopsies.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, SOLID ORGAN NEOPLASM, DNA
ANALYSIS, AND RNA ANALYSIS WHEN PERFORMED, 5-50 GENES (EG, ALK, BRAF,
CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, PIK3CA,
PTEN, RET), INTERROGATION FOR SEQUENCE VARIANTS AND COPY NUMBER
VARIANTS OR REARRANGEMENTS, IF PERFORMED
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
C38.4
C45.0
Malignant neoplasm of trachea
Malignant neoplasm of unspecified main bronchus
Malignant neoplasm of right main bronchus
Malignant neoplasm of left main bronchus
Malignant neoplasm of upper lobe, unspecified bronchus or lung
Malignant neoplasm of upper lobe, right bronchus or lung
Malignant neoplasm of upper lobe, left bronchus or lung
Malignant neoplasm of middle lobe, bronchus or lung
Malignant neoplasm of lower lobe, unspecified bronchus or lung
Malignant neoplasm of lower lobe, right bronchus or lung
Malignant neoplasm of lower lobe, left bronchus or lung
Malignant neoplasm of overlapping sites of unspecified bronchus and lung
Malignant neoplasm of overlapping sites of right bronchus and lung
Malignant neoplasm of overlapping sites of left bronchus and lung
Malignant neoplasm of unspecified part of unspecified bronchus or lung
Malignant neoplasm of unspecified part of right bronchus or lung
Malignant neoplasm of unspecified part of left bronchus or lung
Malignant neoplasm of pleura
Mesothelioma of pleura
Indications and Limitations of Coverage
Genomic Sequential Analysis Panel represented by CPT 81445 will be considered
reasonable and necessary in the evaluation of tumor tissue in the following clinical
circumstances:
•Newly diagnosed patients with advanced (stage IIIB or IV) NSCLC, who are not
treatable by resection or radiation with curative intent, and who are suitable candidates
for therapy at the time of testing.
•Previously diagnosed patients with advanced (stage IIIB or IV) NSCLC, who have not
responded to at least one systemic therapy, or who have progressed following
resection. The patient must be a candidate for treatment at the time of the testing.
•Previously diagnosed patients with advanced (stage IIIB or IV) NSCLC, who have
been resistant to at least one targeted therapy, are able to undergo tumor tissue
biopsy for testing, and who are suitable candidates for additional treatment at the time
of testing.
Utilization Guidelines
Screening services such as pre-symptomatic genetic tests and services used to detect
an undiagnosed disease or disease predisposition are not a Medicare benefit and are
not covered. Similarly, Medicare may not reimburse the costs of tests/examinations
that assess the risk of a condition unless the risk assessment clearly and directly
effects the management of the patient.
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-10-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.
Last Updated:
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.
4/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Heavy Metal Testing (pg. 1 of 10)
Data Source: Local Coverage Determination
CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,
83655, 83785, 83825, 83885, 84255, 84285, 84630
for Heavy Metal Testing (L35074)
LCD Description: The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy
metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not
for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous
abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and
peripheral nervous system toxicity. Other metals cause pulmonary illness. However, before any testing for heavy metal is ordered, a detailed medical history of the patient must
be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. While classified as
heavy metals, this policy does not include iron or lithium since the former is typically tested for anemia issues and the latter is typically tested for monitoring of medications. In
addition, iron testing is covered under the National Coverage Determination 190.18 (Serum Iron Studies).
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be
used as a complete reference.
CPT 82108, Aluminum- Serum aluminum testing is payable for beneficiaries
who have been on dialysis with evidence suggesting aluminum toxicity, or
for beneficiaries with chronic industrial exposure history
F06.8
F11.121
F11.122
F11.14
F11.188
F11.221
F11.24
F11.288
F11.921
F11.929
F11.94
F11.988
F12.121
F12.129
F12.159
F12.188
F12.221
F12.229
F12.288
F12.921
F12.929
Other specified mental disorders due to known physiological condition
Opioid abuse with intoxication delirium
Opioid abuse with intoxication with perceptual disturbance
Opioid abuse with opioid-induced mood disorder
Opioid abuse with other opioid-induced disorder
Opioid dependence with intoxication delirium
Opioid dependence with opioid-induced mood disorder
Opioid dependence with other opioid-induced disorder
Opioid use, unspecified with intoxication delirium
Opioid use, unspecified with intoxication, unspecified
Opioid use, unspecified with opioid-induced mood disorder
Opioid use, unspecified with other opioid-induced disorder
Cannabis abuse with intoxication delirium
Cannabis abuse with intoxication, unspecified
Cannabis abuse with psychotic disorder, unspecified
Cannabis abuse with other cannabis-induced disorder
Cannabis dependence with intoxication delirium
Cannabis dependence with intoxication, unspecified
Cannabis dependence with other cannabis-induced disorder
Cannabis use, unspecified with intoxication delirium
Cannabis use, unspecified with intoxication, unspecified
F12.988
F13.121
F13.129
F13.14
F13.159
F13.188
F13.221
F13.229
F13.24
F13.259
F13.26
F13.27
F13.921
F13.929
F13.94
Cannabis use, unspecified with other cannabis-induced disorder
Sedative, hypnotic or anxiolytic abuse with intoxication delirium
Sedative, hypnotic or anxiolytic abuse with intoxication, unspecified
Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced mood disorder
Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolyticinduced psychotic disorder, unspecified
Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or
anxiolytic-induced disorder
Sedative, hypnotic or anxiolytic dependence with intoxication delirium
Sedative, hypnotic or anxiolytic dependence with intoxication, unspecified
Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or
anxiolytic-induced mood disorder
Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or
anxiolytic-induced psychotic disorder, unspecified
Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or
anxiolytic-induced persisting amnestic disorder
Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or
anxiolytic-induced persisting dementia
Sedative, hypnotic or anxiolytic use, unspecified with intoxication delirium
Sedative, hypnotic or anxiolytic use, unspecified with intoxication,
unspecified
Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or
anxiolytic-induced mood disorder
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Heavy Metal Testing (pg. 2 of 10)
Data Source: Local Coverage Determination
CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,
83655, 83785, 83825, 83885, 84255, 84285, 84630
(LCD): Heavy Metal Testing (L35074)
LCD Description: The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy
metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not
for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous
abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and
peripheral nervous system toxicity. Other metals cause pulmonary illness. However, before any testing for heavy metal is ordered, a detailed medical history of the patient must
be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. While classified as
heavy metals, this policy does not include iron or lithium since the former is typically tested for anemia issues and the latter is typically tested for monitoring of medications. In
addition, iron testing is covered under the National Coverage Determination 190.18 (Serum Iron Studies).
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be
used as a complete reference.
F13.96
F13.97
F13.988
F14.121
F14.129
F14.14
F14.188
F14.221
F14.229
F14.24
F14.288
F14.921
F14.929
F14.94
F14.988
F15.121
F15.129
F15.14
F15.188
F15.221
F15.229
F15.24
Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic
or anxiolytic-induced persisting amnestic disorder
Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic
or anxiolytic-induced persisting dementia
Sedative, hypnotic or anxiolytic use, unspecified with other sedative,
hypnotic or anxiolytic-induced disorder
Cocaine abuse with intoxication with delirium
Cocaine abuse with intoxication, unspecified
Cocaine abuse with cocaine-induced mood disorder
Cocaine abuse with other cocaine-induced disorder
Cocaine dependence with intoxication delirium
Cocaine dependence with intoxication, unspecified
Cocaine dependence with cocaine-induced mood disorder
Cocaine dependence with other cocaine-induced disorder
Cocaine use, unspecified with intoxication delirium
Cocaine use, unspecified with intoxication, unspecified
Cocaine use, unspecified with cocaine-induced mood disorder
Cocaine use, unspecified with other cocaine-induced disorder
Other stimulant abuse with intoxication delirium
Other stimulant abuse with intoxication, unspecified
Other stimulant abuse with stimulant-induced mood disorder
Other stimulant abuse with other stimulant-induced disorder
Other stimulant dependence with intoxication delirium
Other stimulant dependence with intoxication, unspecified
Other stimulant dependence with stimulant-induced mood disorder
F15.288 Other stimulant dependence with other stimulant-induced disorder
F15.921 Other stimulant use, unspecified with intoxication delirium
F15.929 Other stimulant use, unspecified with intoxication, unspecified
F15.94
Other stimulant use, unspecified with stimulant-induced mood disorder
F15.988 Other stimulant use, unspecified with other stimulant-induced disorder
F16.121 Hallucinogen abuse with intoxication with delirium
F16.129 Hallucinogen abuse with intoxication, unspecified
F16.14
Hallucinogen abuse with hallucinogen-induced mood disorder
F16.188 Hallucinogen abuse with other hallucinogen-induced disorder
F16.221 Hallucinogen dependence with intoxication with delirium
F16.229 Hallucinogen dependence with intoxication, unspecified
F16.24
Hallucinogen dependence with hallucinogen-induced mood disorder
F16.288 Hallucinogen dependence with other hallucinogen-induced disorder
F16.921 Hallucinogen use, unspecified with intoxication with delirium
F16.929 Hallucinogen use, unspecified with intoxication, unspecified
F16.94
Hallucinogen use, unspecified with hallucinogen-induced mood disorder
F16.988 Hallucinogen use, unspecified with other hallucinogen-induced disorder
F18.121 Inhalant abuse with intoxication delirium
F18.129 Inhalant abuse with intoxication, unspecified
F18.14
Inhalant abuse with inhalant-induced mood disorder
F18.17
Inhalant abuse with inhalant-induced dementia
F18.188 Inhalant abuse with other inhalant-induced disorder
F18.221 Inhalant dependence with intoxication delirium
F18.229 Inhalant dependence with intoxication, unspecified
F18.24 Inhalant dependence with inhalant-induced mood disorder
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Heavy Metal Testing (pg. 3 of 10)
Data Source: Local Coverage Determination
CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,
83655, 83785, 83825, 83885, 84255, 84285, 84630
(LCD): Heavy Metal Testing (L35074)
LCD Description: The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy
metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not
for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous
abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and
peripheral nervous system toxicity. Other metals cause pulmonary illness. However, before any testing for heavy metal is ordered, a detailed medical history of the patient must
be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. While classified as
heavy metals, this policy does not include iron or lithium since the former is typically tested for anemia issues and the latter is typically tested for monitoring of medications. In
addition, iron testing is covered under the National Coverage Determination 190.18 (Serum Iron Studies).
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be
used as a complete reference.
F19.288 Other psychoactive substance dependence with other psychoactive
F18.27 Inhalant dependence with inhalant-induced dementia
substance-induced disorder
F18.288 Inhalant dependence with other inhalant-induced disorder
F19.921 Other psychoactive substance use, unspecified with intoxication with delirium
F18.921 Inhalant use, unspecified with intoxication with delirium
F19.929 Other psychoactive substance use, unspecified with intoxication, unspecified
F18.929 Inhalant use, unspecified with intoxication, unspecified
F19.94 Other psychoactive substance use, unspecified with psychoactive substanceF18.94 Inhalant use, unspecified with inhalant-induced mood disorder
induced mood disorder
F18.97 Inhalant use, unspecified with inhalant-induced persisting dementia
F19.96 Other psychoactive substance use, unspecified with psychoactive substanceF18.988 Inhalant use, unspecified with other inhalant-induced disorder
Induced persisting amnestic disorder
F19.121 Other psychoactive substance abuse with intoxication delirium
F19.97 Other psychoactive substance use, unspecified with psychoactive substanceF19.129 Other psychoactive substance abuse with intoxication, unspecified
induced persisting dementia
F19.14 Other psychoactive substance abuse with psychoactive substanceF19.988 Other psychoactive substance use, unspecified with other psychoactive
induced mood disorder
substance-induced disorder
F19.16 Other psychoactive substance abuse with psychoactive substanceN18.1
Chronic kidney disease, stage 1
induced persisting amnestic disorder
N18.2
Chronic kidney disease, stage 2 (mild)
F19.17 Other psychoactive substance abuse with psychoactive substanceN18.3
Chronic kidney disease, stage 3 (moderate)
induced persisting dementia
N18.4
Chronic kidney disease, stage 4 (severe)
F19.188 Other psychoactive substance abuse with other psychoactive substanceN18.5
Chronic kidney disease, stage 5
induced disorder
N18.6
End stage renal disease
F19.221 Other psychoactive substance dependence with intoxication delirium
N18.9
Chronic kidney disease, unspecified
F19.229 Other psychoactive substance dependence with intoxication, unspecified
T47.0X4A Poisoning by histamine H2-receptor blockers, undetermined, initial
F19.24 Other psychoactive substance dependence with psychoactive
encounter
substance- induced mood disorder
T47.0X4D Poisoning by histamine H2-receptor blockers, undetermined, subsequent
F19.26 Other psychoactive substance dependence with psychoactive substanceencounter
induced persisting amnestic disorder
T47.0X4S Poisoning by histamine H2-receptor blockers, undetermined, sequela
F19.27 Other psychoactive substance dependence with psychoactive substanceT47.1X4A Poisoning by other antacids and anti-gastric-secretion drugs,
induced persisting dementia
undetermined, initial encounter
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Heavy Metal Testing (pg. 4 of 10)
Data Source: Local Coverage Determination
CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,
83655, 83785, 83825, 83885, 84255, 84285, 84630
(LCD): Heavy Metal Testing (L35074)
LCD Description: The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy
metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not
for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous
abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and
peripheral nervous system toxicity. Other metals cause pulmonary illness. However, before any testing for heavy metal is ordered, a detailed medical history of the patient must
be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. While classified as
heavy metals, this policy does not include iron or lithium since the former is typically tested for anemia issues and the latter is typically tested for monitoring of medications. In
addition, iron testing is covered under the National Coverage Determination 190.18 (Serum Iron Studies).
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be
used as a complete reference.
T47.1X4D Poisoning by other antacids and anti-gastric-secretion drugs,
undetermined, subsequent encounter
T47.1X4S Poisoning by other antacids and anti-gastric-secretion drugs,
undetermined, sequela
T56.894A Toxic effect of other metals, undetermined, initial encounter
T56.894D Toxic effect of other metals, undetermined, subsequent encounter
T56.894S Toxic effect of other metals, undetermined, sequela
T82.898A Other specified complication of vascular prosthetic devices, implants
and grafts, initial encounter
T82.898D Other specified complication of vascular prosthetic devices, implants
and grafts, subsequent encounter
T82.898S Other specified complication of vascular prosthetic devices, implants
and grafts, sequela
CPT 83018 , Antimony- Serum and/or urine antimony testing is payable for
beneficiaries with documented treatment in the past with antileishmaniasis
agents or with documented chronic antimony industrial exposure history.
B55.9
Leishmaniasis, unspecified
T56.891A Toxic effect of other metals, accidental (unintentional), initial encounter
T56.891D Toxic effect of other metals, accidental (unintentional), subsequent
encounter
T56.891S Toxic effect of other metals, accidental (unintentional), sequela
CPT 82175 , Arsenic- Serum and whole blood and/or urine arsenic testing is
payable for beneficiaries with unexplained peripheral neuropathies, industrial
exposure to arsenic, histories of arsenic pesticide exposure, unexplained
encephalopathies, unexplained weight loss, chronic glomerulonephritis, bone
marrow hypoplasia, or melanosis of skin, unexplained chronic diarrhea,
persistent abdominal pain, or nausea and vomiting.
D61.1
Drug-induced aplastic anemia
D61.2
Aplastic anemia due to other external agents
D61.3
Idiopathic aplastic anemia
D61.89 Other specified aplastic anemias and other bone marrow failure syndromes
G60.0
Hereditary motor and sensory neuropathy
G60.2
Neuropathy in association with hereditary ataxia
G60.9
Hereditary and idiopathic neuropathy, unspecified
G61.1
Serum neuropathy
G62.2
Polyneuropathy due to other toxic agents
G62.82 Radiation-induced polyneuropathy
G93.40 Encephalopathy, unspecified
G93.41 Metabolic encephalopathy
G93.49 Other encephalopathy
I67.83
Posterior reversible encephalopathy syndrome
K52.21
Food protein-induced enterocolitis syndrome
K52.22
Food protein-induced enteropathy
K52.29
Other allergic and dietetic gastroenteritis and colitis
K52.89
Other specified noninfective gastroenteritis and colitis
K63.4
Enteroptosis
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Heavy Metal Testing (pg. 5 of 10)
Data Source: Local Coverage Determination
CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,
83655, 83785, 83825, 83885, 84255, 84285, 84630
(LCD): Heavy Metal Testing (L35074)
LCD Description: The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy
metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not
for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous
abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and
peripheral nervous system toxicity. Other metals cause pulmonary illness. However, before any testing for heavy metal is ordered, a detailed medical history of the patient must
be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. While classified as
heavy metals, this policy does not include iron or lithium since the former is typically tested for anemia issues and the latter is typically tested for monitoring of medications. In
addition, iron testing is covered under the National Coverage Determination 190.18 (Serum Iron Studies).
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be
used as a complete reference.
K63.89
K92.89
L23.1
L23.5
L24.5
L25.3
N03.9
R11.2
R19.7
R63.4
T57.0X4A
Other specified diseases of intestine
Other specified diseases of the digestive system
Allergic contact dermatitis due to adhesives
Allergic contact dermatitis due to other chemical products
Irritant contact dermatitis due to other chemical products
Unspecified contact dermatitis due to other chemical products
Chronic nephritic syndrome with unspecified morphologic changes
Nausea with vomiting, unspecified
Diarrhea, unspecified
Abnormal weight loss
Toxic effect of arsenic and its compounds, undetermined, initial
encounter
T57.0X4D Toxic effect of arsenic and its compounds, undetermined, subsequent
encounter
T57.0X4S Toxic effect of arsenic and its compounds, undetermined, sequela
CPT 83018, Barium- Serum and or/urine barium testing is payable for
beneficiaries with pulmonary disease with industrial exposure to barium or
unexplained flaccid paralysis.
J98.4
Other disorders of lung
T56.894A Toxic effect of other metals, undetermined, initial encounter
T56.894D Toxic effect of other metals, undetermined, subsequent encounter
T56.894S Toxic effect of other metals, undetermined, sequela
CPT 83018: Beryllium- Serum and/or urine beryllium testing is payable for
beneficiaries with pulmonary disease with industrial exposure to beryllium.
J98.4
Other disorders of lung
T56.7X4A Toxic effect of beryllium and its compounds, undetermined, initial
encounter
T56.7X4D Toxic effect of beryllium and its compounds, undetermined,
subsequent encounter
T56.7X4S Toxic effect of beryllium and its compounds, undetermined, sequela
CPT 83018: Bismuth- Serum and/or urine bismuth testing is payable for
beneficiaries with bismuth lines on their gums, methemoglobinemia,
unexplained pathological fractures, or a history of bismuth medicine abuse.
D74.8
Other methemoglobinemias
D74.9
Methemoglobinemia, unspecified
K05.5
Other periodontal diseases
M84.40XA Pathological fracture, unspecified site, initial encounter for fracture
M84.40XD Pathological fracture, unspecified site, subsequent encounter for
fracture with routine healing
M84.40XS Pathological fracture, unspecified site, sequela
T56.894A Toxic effect of other metals, undetermined, initial encounter
T56.894D Toxic effect of other metals, undetermined, subsequent encounter
T56.894S Toxic effect of other metals, undetermined, sequela
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Heavy Metal Testing (pg . 6 of 10)
Data Source: Local Coverage Determination
CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,
83655, 83785, 83825, 83885, 84255, 84285, 84630
(LCD): Heavy Metal Testing (L35074)
LCD Description: The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy
metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not
for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous
abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and
peripheral nervous system toxicity. Other metals cause pulmonary illness. However, before any testing for heavy metal is ordered, a detailed medical history of the patient must
be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. While classified as
heavy metals, this policy does not include iron or lithium since the former is typically tested for anemia issues and the latter is typically tested for monitoring of medications. In
addition, iron testing is covered under the National Coverage Determination 190.18 (Serum Iron Studies).
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be
used as a complete reference.
CPT 82300, Cadmium- Cadmium. Serum and whole blood and/or urine
cadmium testing is payable for beneficiaries with an exposure to cadmium
with evidence of pulmonary disease or unexplained renal failure.
J98.4
Other disorders of lung
N19
Unspecified kidney failure
T56.3X4A Toxic effect of cadmium and its compounds, undetermined, initial
encounter
T56.3X4D Toxic effect of cadmium and its compounds, undetermined,
subsequent encounter
T56.3X4S Toxic effect of cadmium and its compounds, undetermined, sequela
CPT 82495, Chromium.- Serum chromium testing is payable for beneficiaries
with an industrial exposure to chromium with evidence of pulmonary
disease.
J98.4
Other disorders of lung
T56.2X4A Toxic effect of chromium and its compounds, undetermined, initial
encounter
T56.2X4D Toxic effect of chromium and its compounds, undetermined,
subsequent encounter
T56.2X4S Toxic effect of chromium and its compounds, undetermined, sequela
CPT 83018: Cobalt. Serum cobalt testing is payable for beneficiaries with an
industrial exposure to cobalt with evidence of pulmonary disease
J98.4
Other disorders of lung
T56.894A Toxic effect of other metals, undetermined, initial encounter
T56.894D Toxic effect of other metals, undetermined, subsequent encounter
T56.894S Toxic effect of other metals, undetermined, sequela
CPT 82525: Copper. Serum copper testing is payable for beneficiaries with an
industrial exposure to copper with evidence of pulmonary disease, or for
beneficiaries with Wilson’s Disease, unexplained cardiomyopathy, unexplained
renal failure, polycythemia. unexplained myelodysplastic syndrome or known
ingestion of zinc.
D46.0 Refractory anemia without ring sideroblasts, so stated
D46.1 Refractory anemia with ring sideroblasts
D46.20 Refractory anemia with excess of blasts, unspecified
D46.21 Refractory anemia with excess of blasts 1
D46.22 Refractory anemia with excess of blasts 2
D46.A Refractory cytopenia with multilineage dysplasia
D46.B Refractory cytopenia with multilineage dysplasia and ring sideroblasts
D46.C Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality
D46.4 Refractory anemia, unspecified
D46.Z Other myelodysplastic syndromes
D46.9 Myelodysplastic syndrome, unspecified
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Heavy Metal Testing (pg. 7 of 10)
Data Source: Local Coverage Determination
CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,
83655, 83785, 83825, 83885, 84255, 84285, 84630
(LCD): Heavy Metal Testing (L35074)
LCD Description: The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy
metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not
for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous
abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and
peripheral nervous system toxicity. Other metals cause pulmonary illness. However, before any testing for heavy metal is ordered, a detailed medical history of the patient must
be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. While classified as
heavy metals, this policy does not include iron or lithium since the former is typically tested for anemia issues and the latter is typically tested for monitoring of medications. In
addition, iron testing is covered under the National Coverage Determination 190.18 (Serum Iron Studies).
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be
used as a complete reference.
E83.00
E83.09
I42.9
J98.4
K73.0
K73.9
K74.60
K74.69
K76.9
N19
Q89.8
R63.3
R74.8
R74.9
T56.894A
T56.894D
T56.894S
Disorder of copper metabolism, unspecified
Other disorders of copper metabolism
Cardiomyopathy, unspecified
Other disorders of lung
Chronic persistent hepatitis, not elsewhere classified
Chronic hepatitis, unspecified
Unspecified cirrhosis of liver
Other cirrhosis of liver
Liver disease, unspecified
Unspecified kidney failure
Other specified congenital malformations
Feeding difficulties
Abnormal levels of other serum enzymes
Abnormal serum enzyme level, unspecified
Toxic effect of other metals, undetermined, initial encounter
Toxic effect of other metals, undetermined, subsequent encounter
Toxic effect of other metals, undetermined, sequela
CPT 83655: Lead. Blood (serum and whole) and/or urine lead testing is
covered if there is documented industrial exposure to lead, documented
avocation exposure to lead, retained bullet fragments at or near joints, a blue
gum line, a history of moonshine abuse, unexplained peripheral
neuropathies, evidence of lead contaminated drinking water, paint stripping,
lead lines on bones on radiographs, or basophilic stippling of red blood cells.
G58.8
G58.9
G60.0
G60.1
G60.2
G60.3
G60.8
G60.9
G93.40
G93.41
G93.49
R71.0
R71.8
R93.6
R93.7
Other specified mononeuropathies
Mononeuropathy, unspecified
Hereditary motor and sensory neuropathy
Refsum's disease
Neuropathy in association with hereditary ataxia
Idiopathic progressive neuropathy
Other hereditary and idiopathic neuropathies
Hereditary and idiopathic neuropathy, unspecified
Encephalopathy, unspecified
Metabolic encephalopathy
Other encephalopathy
Precipitous drop in hematocrit
Other abnormality of red blood cells
Abnormal findings on diagnostic imaging of limbs
Abnormal findings on diagnostic imaging of other parts of
musculoskeletal system
T56.0X4A Toxic effect of lead and its compounds, undetermined, initial encounter
T56.0X4D Toxic effect of lead and its compounds, undetermined, subsequent
encounter
T56.0X4S Toxic effect of lead and its compounds, undetermined, sequela
CPT 83785, Manganese- Serum manganese testing is covered for beneficiaries
with documented industrial exposure to manganese.
G25.70 Drug induced movement disorder, unspecified
G25.71 Drug induced akathisia
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Heavy Metal Testing (pg. 8 of 10)
Data Source: Local Coverage Determination
CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,
83655, 83785, 83825, 83885, 84255, 84285, 84630
(LCD): Heavy Metal Testing (L35074)
LCD Description: The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy
metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not
for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous
abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and
peripheral nervous system toxicity. Other metals cause pulmonary illness. However, before any testing for heavy metal is ordered, a detailed medical history of the patient must
be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. While classified as
heavy metals, this policy does not include iron or lithium since the former is typically tested for anemia issues and the latter is typically tested for monitoring of medications. In
addition, iron testing is covered under the National Coverage Determination 190.18 (Serum Iron Studies).
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be
used as a complete reference.
G25.79
G25.89
G25.9
G26
Other drug induced movement disorders
Other specified extrapyramidal and movement disorders
Extrapyramidal and movement disorder, unspecified
Extrapyramidal and movement disorders in diseases classified
elsewhere
R63.3
Feeding difficulties
T57.2X4A Toxic effect of manganese and its compounds, undetermined, initial
encounter
T57.2X4D Toxic effect of manganese and its compounds, undetermined,
subsequent encounter
T57.2X4S Toxic effect of manganese and its compounds, undetermined, sequela
I69.193
I69.293
I69.393
I69.893
I69.993
N19
R27.0
R27.8
R27.9
T37.8X1A
T37.8X1D
CPT 83825, Mercury- Serum, whole blood, and/or urine mercury testing is
covered for beneficiaries with documented industrial exposure to mercury,
with a blue line in their mouth, those with a history of laxative abuse, with a
history of pesticide exposure, mercury spillage with vacuuming of the liquid
metal, unexplained renal failure, or a history of skin lightening treatments.
G11.1
Early-onset cerebellar ataxia
G25.70 Drug induced movement disorder, unspecified
G25.71 Drug induced akathisia
G25.79 Other drug induced movement disorders
G25.89 Other specified extrapyramidal and movement disorders
G25.9
Extrapyramidal and movement disorder, unspecified
G26
Extrapyramidal and movement disorders in diseases classified elsewhere
I69.093
Ataxia following nontraumatic subarachnoid hemorrhage
T37.8X1S
T47.4X4A
T47.4X4D
T47.4X4S
T49.8X4A
T49.8X4D
T49.8X4S
T56.1X4A
T56.1X4D
Ataxia following nontraumatic intracerebral hemorrhage
Ataxia following other nontraumatic intracranial hemorrhage
Ataxia following cerebral infarction
Ataxia following other cerebrovascular disease
Ataxia following unspecified cerebrovascular disease
Unspecified kidney failure
Ataxia, unspecified
Other lack of coordination
Unspecified lack of coordination
Poisoning by other specified systemic anti-infectives and antiparasitics,
accidental (unintentional), initial encounter
Poisoning by other specified systemic anti-infectives and antiparasitics,
accidental (unintentional), subsequent encounter
Poisoning by other specified systemic anti-infectives and antiparasitics,
accidental (unintentional), sequela
Poisoning by other laxatives, undetermined, initial encounter
Poisoning by other laxatives, undetermined, subsequent encounter
Poisoning by other laxatives, undetermined, sequela
Poisoning by other topical agents, undetermined, initial encounter
Poisoning by other topical agents, undetermined, subsequent encounter
Poisoning by other topical agents, undetermined, sequela
Toxic effect of mercury and its compounds, undetermined, initial
encounter
Toxic effect of mercury and its compounds, undetermined, subsequent
encounter
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Heavy Metal Testing (pg. 9 of 10)
Data Source: Local Coverage Determination
CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,
83655, 83785, 83825, 83885, 84255, 84285, 84630
(LCD): Heavy Metal Testing (L35074)
LCD Description: The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy
metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not
for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous
abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and
peripheral nervous system toxicity. Other metals cause pulmonary illness. However, before any testing for heavy metal is ordered, a detailed medical history of the patient must
be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. While classified as
heavy metals, this policy does not include iron or lithium since the former is typically tested for anemia issues and the latter is typically tested for monitoring of medications. In
addition, iron testing is covered under the National Coverage Determination 190.18 (Serum Iron Studies).
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be
used as a complete reference.
T56.1X4S Toxic effect of mercury and its compounds, undetermined, sequela
CPT 83018, Molybdenum. Serum molybdenum testing is covered for
beneficiaries with documented industrial exposure to molybdenum.
T56.894A Toxic effect of other metals, undetermined, initial encounter
T56.894D Toxic effect of other metals, undetermined, subsequent encounter
T56.894S Toxic effect of other metals, undetermined, sequela
CPT 83885, Nickel- Serum and/or urine nickel testing is covered for
beneficiaries with documented industrial exposure to nickel, unexplained
renal failure, unexplained pulmonary disease.
J98.4
Other disorders of lung
N19
Unspecified kidney failure
T56.894A Toxic effect of other metals, undetermined, initial encounter
T56.894D Toxic effect of other metals, undetermined, subsequent encounter
T56.894S Toxic effect of other metals, undetermined, sequela
CPT 84255, Selenium- Serum and/or urine selenium testing is covered for
beneficiaries with documented industrial exposure to selenium or on chronic
renal dialysis.
N19
Unspecified kidney failure
T56.894A Toxic effect of other metals, undetermined, initial encounter
T56.894D Toxic effect of other metals, undetermined, subsequent encounter
T56.894S Toxic effect of other metals, undetermined, sequela
CPT 83018, Thallium- Serum thallium testing is covered for beneficiaries with
documented industrial exposure to thallium and unexplained ataxia.
G62.2
Polyneuropathy due to other toxic agents
R27.0
Ataxia, unspecified
R27.8
Other lack of coordination
R27.9
Unspecified lack of coordination
T56.814A Toxic effect of thallium, undetermined, initial encounter
T56.814D Toxic effect of thallium, undetermined, subsequent encounter
T56.814S Toxic effect of thallium, undetermined, sequela
CPT 83018, Tin- Serum tin testing is covered for beneficiaries with documented
industrial exposure to tin.
T56.6X4A Toxic effect of tin and its compounds, undetermined, initial encounter
T56.6X4D Toxic effect of tin and its compounds, undetermined, subsequent encounter
T56.6X4S Toxic effect of tin and its compounds, undetermined, sequela
CPT 83018, Titanium- Serum titanium testing is covered for beneficiaries with
documented industrial exposure to titanium.
T56.894A Toxic effect of other metals, undetermined, initial encounter
T56.894D Toxic effect of other metals, undetermined, subsequent encounter
T56.894S Toxic effect of other metals, undetermined, sequela
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Heavy Metal Testing (pg. 10 of 10)
Data Source: Local Coverage Determination
CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,
83655, 83785, 83825, 83885, 84255, 84285, 84630
(LCD): Heavy Metal Testing (L35074)
LCD Description: The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy
metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not
for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous
abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and
peripheral nervous system toxicity. Other metals cause pulmonary illness. However, before any testing for heavy metal is ordered, a detailed medical history of the patient must
be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. While classified as
heavy metals, this policy does not include iron or lithium since the former is typically tested for anemia issues and the latter is typically tested for monitoring of medications. In
addition, iron testing is covered under the National Coverage Determination 190.18 (Serum Iron Studies).
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be
used as a complete reference.
CPT 84630, Zinc. Serum zinc and/or urine testing is covered for beneficiaries
with documented industrial exposure to zinc, on chronic renal dialysis, with
malabsorption syndromes, Crohn’s disease, unexplained myelodysplastic
syndrome or known ingestion of zinc.
D46.0
D46.1
D46.20
D46.21
D46.22
D46.A
D46.B
D46.C
Refractory anemia without ring sideroblasts, so stated
Refractory anemia with ring sideroblasts
Refractory anemia with excess of blasts, unspecified
Refractory anemia with excess of blasts 1
Refractory anemia with excess of blasts 2
Refractory cytopenia with multilineage dysplasia
Refractory cytopenia with multilineage dysplasia and ring sideroblasts
Myelodysplastic syndrome with isolated del(5q) chromosomal
abnormality
D46.4
Refractory anemia, unspecified
D46.Z
Other myelodysplastic syndromes
D46.9
Myelodysplastic syndrome, unspecified
K50.90
Crohn's disease, unspecified, without complications
K50.918 Crohn's disease, unspecified, with other complication
K50.919 Crohn's disease, unspecified, with unspecified complications
K90.9
Intestinal malabsorption, unspecified
N19
Unspecified kidney failure
R63.3
Feeding difficulties
T56.5X4A Toxic effect of zinc and its compounds, undetermined, initial encounter
T56.5X4D Toxic effect of zinc and its compounds, undetermined, subsequent
encounter
T56.5X4S Toxic effect of zinc and its compounds, undetermined, sequela
The term heavy metal testing is historically used to describe elements such as lead,
arsenic, mercury, cadmium, and chromium. In general, all of the heavy metals in
inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and
diarrhea. The next most consistent toxicity for the heavy metals as a group, but not for
every heavy metal, is renal toxicity. A further generalization is that each member of the
heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous
abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and
premalignant and malignant lesions. Several of the heavy metals produce central and
peripheral nervous system toxicity. Other metals cause pulmonary illness.
However, before any testing for heavy metal is ordered, a detailed medical history of
the patient must be obtained, including a careful documentation of occupational and
avocational exposure to these toxins. A complete physical examination must be done.
While classified as heavy metals, this policy does not include iron or lithium since the
former is typically tested for anemia issues and the latter is typically tested for
monitoring of medications. In addition, iron testing is covered under the National
Coverage Determination 190.18 (Serum Iron Studies).
TESTING FOR THE FOLLOWING METALS IS NON-COVERED: BORON,
PHOSPHOROUS, SILICA, STRONTIUM, SULFUR, URANIUM, VANADIUM
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg.1 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
Group 1 Paragraph:
TIER 1 COVERED MOLECULAR PATHOLOGY PROCEDURES
Limited coverage may be provided for the genetic tests, submitted under the following
CPT codes:
Note: Please refer to the Indications and Limitations of Coverage section and the ICD10-CM diagnosis to CPT procedure groupings. Not all procedure codes have related
diagnosis codes listed.
Group 1 Codes:
81170 ABL1 (ABL PROTO-ONCOGENE 1, NON-RECEPTOR TYROSINE KINASE) (EG,
ACQUIRED IMATINIB TYROSINE KINASE INHIBITOR RESISTANCE), GENE
ANALYSIS, VARIANTS IN THE KINASE DOMAIN
81206 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION
ANALYSIS; MAJOR BREAKPOINT, QUALITATIVE OR QUANTITATIVE
81207 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION
ANALYSIS; MINOR BREAKPOINT, QUALITATIVE OR QUANTITATIVE
81208 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS LEUKEMIA) TRANSLOCATION
ANALYSIS; OTHER BREAKPOINT, QUALITATIVE OR QUANTITATIVE
81210 BRAF (B-RAF PROTO-ONCOGENE, SERINE/THREONINE KINASE) (EG, COLON
CANCER, MELANOMA), GENE ANALYSIS, V600 VARIANT(S)
81218 CEBPA (CCAAT/ENHANCER BINDING PROTEIN [C/EBP], ALPHA) (EG, ACUTE
MYELOID LEUKEMIA), GENE ANALYSIS, FULL GENE SEQUENCE
81225 CYP2C19 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 19) (EG,
DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *8, *17)
81225 CYP2C19 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 19) (EG,
DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *4, *8, *17)
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)
81235 EGFR (EPIDERMAL GROWTH FACTOR RECEPTOR) (EG, NON-SMALL CELL LUNG
CANCER) GENE ANALYSIS, COMMON VARIANTS (EG, EXON 19 LREA DELETION,
L858R, T790M, G719A, G719S, L861Q)
81245 FLT3 (FMS-RELATED TYROSINE KINASE 3) (EG, ACUTE MYELOID LEUKEMIA),
GENE ANALYSIS; INTERNAL TANDEM DUPLICATION (ITD) VARIANTS (IE, EXONS
14, 15)
81246 FLT3 (FMS-RELATED TYROSINE KINASE 3) (EG, ACUTE MYELOID LEUKEMIA),
GENE ANALYSIS; TYROSINE KINASE DOMAIN (TKD) VARIANTS (EG, D835, I836)
81256 HFE (HEMOCHROMATOSIS) (EG, HEREDITARY HEMOCHROMATOSIS) GENE
ANALYSIS, COMMON VARIANTS (EG, C282Y, H63D)
81261 IGH@ (IMMUNOGLOBULIN HEAVY CHAIN LOCUS) (EG, LEUKEMIAS AND
LYMPHOMAS, B-CELL), GENE REARRANGEMENT ANALYSIS TO DETECT
ABNORMAL CLONAL POPULATION(S); AMPLIFIED METHODOLOGY (EG,
POLYMERASE CHAIN REACTION)
81262 GH@ (IMMUNOGLOBULIN HEAVY CHAIN LOCUS) (EG, LEUKEMIAS AND
LYMPHOMAS, B-CELL), GENE REARRANGEMENT ANALYSIS TO DETECT
ABNORMAL CLONAL POPULATION(S); DIRECT PROBE METHODOLOGY (EG,
SOUTHERN BLOT)
81263 IGH@ (IMMUNOGLOBULIN HEAVY CHAIN LOCUS) (EG, LEUKEMIA AND
LYMPHOMA, B-CELL), VARIABLE REGION SOMATIC MUTATION ANALYSIS
81264 IGK@ (IMMUNOGLOBULIN KAPPA LIGHT CHAIN LOCUS) (EG, LEUKEMIA AND
LYMPHOMA, B-CELL), GENE REARRANGEMENT ANALYSIS, EVALUATION TO
DETECT ABNORMAL CLONAL POPULATION(S)
81270 JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE DISORDER) GENE
ANALYSIS, P.VAL617PHE (V617F) VARIANT
81272 KIT (V-KIT HARDY-ZUCKERMAN 4 FELINE SARCOMA VIRAL ONCOGENE
HOMOLOG) (EG, GASTROINTESTINAL STROMAL TUMOR [GIST], ACUTE MYELOID
LEUKEMIA, MELANOMA), GENE ANALYSIS, TARGETED SEQUENCE ANALYSIS
(EG, EXONS 8, 11, 13, 17, 18)
81273 KIT (V-KIT HARDY-ZUCKERMAN 4 FELINE SARCOMA VIRAL ONCOGENE
HOMOLOG) (EG, MASTOCYTOSIS), GENE ANALYSIS, D816 VARIANT(S)
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 2 of 17)
Data Source: Local Coverage Determination (LCD):
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
81275 KRAS (KIRSTEN RAT SARCOMA VIRAL ONCOGENE HOMOLOG) (EG,
CARCINOMA) GENE ANALYSIS; VARIANTS IN EXON 2 (EG, CODONS 12 AND 13)
81276 KRAS (KIRSTEN RAT SARCOMA VIRAL ONCOGENE HOMOLOG) (EG,
CARCINOMA) GENE ANALYSIS; ADDITIONAL VARIANT(S) (EG, CODON 61, CODON
146)
81287 MGMT (O-6-METHYLGUANINE-DNA METHYLTRANSFERASE) (EG, GLIOBLASTOMA
MULTIFORME), METHYLATION ANALYSIS
81310 NPM1 (NUCLEOPHOSMIN) (EG, ACUTE MYELOID LEUKEMIA) GENE ANALYSIS,
EXON 12 VARIANTS
81311 NRAS (NEUROBLASTOMA RAS VIRAL [V-RAS] ONCOGENE HOMOLOG) (EG,
COLORECTAL CARCINOMA), GENE ANALYSIS, VARIANTS IN EXON 2 (EG,
CODONS 12 AND 13) AND EXON 3 (EG, CODON 61)
81314 PDGFRA (PLATELET-DERIVED GROWTH FACTOR RECEPTOR, ALPHA
POLYPEPTIDE) (EG, GASTROINTESTINAL STROMAL TUMOR [GIST]), GENE
ANALYSIS, TARGETED SEQUENCE ANALYSIS (EG, EXONS 12, 18)
81332 SERPINA1 (SERPIN PEPTIDASE INHIBITOR, CLADE A, ALPHA-1
ANTIPROTEINASE, ANTITRYPSIN, MEMBER 1) (EG, ALPHA-1-ANTITRYPSIN
DEFICIENCY), GENE ANALYSIS, COMMON VARIANTS (EG, *S AND *Z)
81370 HLA CLASS I AND II TYPING, LOW RESOLUTION (EG, ANTIGEN EQUIVALENTS);
HLA-A, -B, -C, -DRB1/3/4/5, AND -DQB1
81371 HLA CLASS I AND II TYPING, LOW RESOLUTION (EG, ANTIGEN EQUIVALENTS);
HLA-A, -B, AND -DRB1 (EG, VERIFICATION TYPING)
81372 HLA CLASS I TYPING, LOW RESOLUTION (EG, ANTIGEN EQUIVALENTS);
COMPLETE (IE, HLA-A, -B, AND -C)
81373 HLA CLASS I TYPING, LOW RESOLUTION (EG, ANTIGEN EQUIVALENTS); ONE
LOCUS (EG, HLA-A, -B, OR -C), EACH
81374 HLA CLASS I TYPING, LOW RESOLUTION (EG, ANTIGEN EQUIVALENTS); ONE
ANTIGEN EQUIVALENT (EG, B*27), EACH
81375 HLA CLASS II TYPING, LOW RESOLUTION (EG, ANTIGEN EQUIVALENTS); HLADRB1/3/4/5 AND -DQB1
81376 HLA CLASS II TYPING, LOW RESOLUTION (EG, ANTIGEN EQUIVALENTS); ONE
LOCUS (EG, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, OR -DPA1), EACH
81377 HLA CLASS II TYPING, LOW RESOLUTION (EG, ANTIGEN EQUIVALENTS); ONE
ANTIGEN EQUIVALENT, EACH
81378 HLA CLASS I AND II TYPING, HIGH RESOLUTION (IE, ALLELES OR ALLELE
GROUPS), HLA-A, -B, -C, AND -DRB1
81379 HLA CLASS I TYPING, HIGH RESOLUTION (IE, ALLELES OR ALLELE GROUPS);
COMPLETE (IE, HLA-A, -B, AND -C)
81380 HLA CLASS I TYPING, HIGH RESOLUTION (IE, ALLELES OR ALLELE GROUPS);
ONE LOCUS (EG, HLA-A, -B, OR -C), EACH
81381 HLA CLASS I TYPING, HIGH RESOLUTION (IE, ALLELES OR ALLELE GROUPS);
ONE ALLELE OR ALLELE GROUP (EG, B*57:01P), EACH
81382 HLA CLASS II TYPING, HIGH RESOLUTION (IE, ALLELES OR ALLELE GROUPS);
ONE LOCUS (EG, HLA-DRB1, -DRB3/4/5, -DQB1, -DQA1, -DPB1, OR -DPA1), EACH
81383 HLA CLASS II TYPING, HIGH RESOLUTION (IE, ALLELES OR ALLELE GROUPS);
ONE ALLELE OR ALLELE GROUP (EG, HLA-DQB1*06:02P), EACH
Group 2 Paragraph: TIER 1 AND TIER 2 MOLECULAR PATHOLOGY
PROCEDURES THAT REQUIRE INDIVIDUAL REVIEW
Coverage may be provided for the genetic tests submitted under the following CPT
codes, if documentation supports medical necessity:
Note: Please refer to the Indications and Limitations of Coverage section and the
ICD-10-CM diagnosis to CPT procedure groupings. Not all procedure codes have
related diagnosis codes listed.
81162 BRCA1, BRCA2 (BREAST CANCER 1 AND 2) (EG, HEREDITARY BREAST AND
OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS AND FULL
DUPLICATION/DELETION ANALYSIS
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 3 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
81211 BRCA1, BRCA2 (BREAST CANCER 1 AND 2) (EG, HEREDITARY BREAST AND
OVARIAN CANCER) GENE ANALYSIS; FULL SEQUENCE ANALYSIS AND COMMON
DUPLICATION/DELETION VARIANTS IN BRCA1 (IE, EXON 13 DEL 3.835KB, EXON
13 DUP 6KB, EXON 14-20 DEL 26KB, EXON 22 DEL 510BP, EXON 8-9 DEL 7.1KB)
81212 BRCA1, BRCA2 (BREAST CANCER 1 AND 2) (EG, HEREDITARY BREAST AND
OVARIAN CANCER) GENE ANALYSIS; 185DELAG, 5385INSC, 6174DELT VARIANTS
81213 BRCA1, BRCA2 (BREAST CANCER 1 AND 2) (EG, HEREDITARY BREAST AND
OVARIAN CANCER) GENE ANALYSIS; UNCOMMON DUPLICATION/DELETION
VARIANTS
81214 BRCA1 (BREAST CANCER 1) (EG, HEREDITARY BREAST AND OVARIAN CANCER)
GENE ANALYSIS; FULL SEQUENCE ANALYSIS AND COMMON
DUPLICATION/DELETION VARIANTS (IE, EXON 13 DEL 3.835KB, EXON 13 DUP
6KB, EXON 14-20 DEL 26KB, EXON 22 DEL 510BP, EXON 8-9 DEL 7.1KB)
81215 BRCA1 (BREAST CANCER 1) (EG, HEREDITARY BREAST AND OVARIAN CANCER)
GENE ANALYSIS; KNOWN FAMILIAL VARIANT
81216 BRCA2 (BREAST CANCER 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER)
GENE ANALYSIS; FULL SEQUENCE ANALYSIS
81217 BRCA2 (BREAST CANCER 2) (EG, HEREDITARY BREAST AND OVARIAN CANCER)
GENE ANALYSIS; KNOWN FAMILIAL VARIANT
81265 COMPARATIVE ANALYSIS USING SHORT TANDEM REPEAT (STR) MARKERS;
PATIENT AND COMPARATIVE SPECIMEN (EG, PRE-TRANSPLANT RECIPIENT
AND DONOR GERMLINE TESTING, POST-TRANSPLANT NON-HEMATOPOIETIC
RECIPIENT GERMLINE [EG, BUCCAL SWAB OR OTHER GERMLINE TISSUE
SAMPLE] AND DONOR TESTING, TWIN ZYGOSITY TESTING, OR MATERNAL CELL
CONTAMINATION OF FETAL CELLS)
81266 COMPARATIVE ANALYSIS USING SHORT TANDEM REPEAT (STR) MARKERS;
EACH ADDITIONAL SPECIMEN (EG, ADDITIONAL CORD BLOOD DONOR,
ADDITIONAL FETAL SAMPLES FROM DIFFERENT CULTURES, OR ADDITIONAL
ZYGOSITY IN MULTIPLE BIRTH PREGNANCIES) (LIST SEPARATELY IN ADDITION
TO CODE FOR PRIMARY PROCEDURE)
81267 CHIMERISM (ENGRAFTMENT) ANALYSIS, POST TRANSPLANTATION SPECIMEN
(EG, HEMATOPOIETIC STEM CELL), INCLUDES COMPARISON TO PREVIOUSLY
PERFORMED BASELINE ANALYSES; WITHOUT CELL SELECTION
81268 CHIMERISM (ENGRAFTMENT) ANALYSIS, POST TRANSPLANTATION SPECIMEN
(EG, HEMATOPOIETIC STEM CELL), INCLUDES COMPARISON TO PREVIOUSLY
PERFORMED BASELINE ANALYSES; WITH CELL SELECTION (EG, CD3, CD33),
EACH CELL TYPE
81288 MLH1 (MUTL HOMOLOG 1, COLON CANCER, NONPOLYPOSIS TYPE 2) (EG,
HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME)
GENE ANALYSIS; PROMOTER METHYLATION ANALYSIS
81291 MTHFR (5,10-METHYLENETETRAHYDROFOLATE REDUCTASE) (EG, HEREDITARY
HYPERCOAGULABILITY) GENE ANALYSIS, COMMON VARIANTS (EG, 677T,
1298C)
81292 MLH1 (MUTL HOMOLOG 1, COLON CANCER, NONPOLYPOSIS TYPE 2) (EG,
HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME)
GENE ANALYSIS; FULL SEQUENCE ANALYSIS
81293 MLH1 (MUTL HOMOLOG 1, COLON CANCER, NONPOLYPOSIS TYPE 2) (EG,
HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME)
GENE ANALYSIS; KNOWN FAMILIAL VARIANTS
81294 MLH1 (MUTL HOMOLOG 1, COLON CANCER, NONPOLYPOSIS TYPE 2) (EG,
HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME)
GENE ANALYSIS; DUPLICATION/DELETION VARIANTS
81295 MSH2 (MUTS HOMOLOG 2, COLON CANCER, NONPOLYPOSIS TYPE 1) (EG,
HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME)
GENE ANALYSIS; FULL SEQUENCE ANALYSIS
81296 MSH2 (MUTS HOMOLOG 2, COLON CANCER, NONPOLYPOSIS TYPE 1) (EG,
HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME)
GENE ANALYSIS; KNOWN FAMILIAL VARIANTS
81297 MSH2 (MUTS HOMOLOG 2, COLON CANCER, NONPOLYPOSIS TYPE 1) (EG,
HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME)
GENE ANALYSIS; DUPLICATION/DELETION VARIANTS
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 4 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
81298 MSH6 (MUTS HOMOLOG 6 [E. COLI]) (EG, HEREDITARY NON-POLYPOSIS
COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; FULL SEQUENCE
ANALYSIS
81299 MSH6 (MUTS HOMOLOG 6 [E. COLI]) (EG, HEREDITARY NON-POLYPOSIS
COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS; KNOWN FAMILIAL
VARIANTS
81300 MSH6 (MUTS HOMOLOG 6 [E. COLI]) (EG, HEREDITARY NON-POLYPOSIS
COLORECTAL CANCER, LYNCH SYNDROME) GENE ANALYSIS;
DUPLICATION/DELETION VARIANTS
81301 MICROSATELLITE INSTABILITY ANALYSIS (EG, HEREDITARY NON-POLYPOSIS
COLORECTAL CANCER, LYNCH SYNDROME) OF MARKERS FOR MISMATCH
REPAIR DEFICIENCY (EG, BAT25, BAT26), INCLUDES COMPARISON OF
NEOPLASTIC AND NORMAL TISSUE, IF PERFORMED
81313 PCA3/KLK3 (PROSTATE CANCER ANTIGEN 3 [NON-PROTEIN
CODING]/KALLIKREIN-RELATED PEPTIDASE 3 [PROSTATE SPECIFIC ANTIGEN])
RATIO (EG, PROSTATE CANCER)
81315 PML/RARALPHA, (T(15;17)), (PROMYELOCYTIC LEUKEMIA/RETINOIC ACID
RECEPTOR ALPHA) (EG, PROMYELOCYTIC LEUKEMIA) TRANSLOCATION
ANALYSIS; COMMON BREAKPOINTS (EG, INTRON 3 AND INTRON 6),
QUALITATIVE OR QUANTITATIVE
81316 PML/RARALPHA, (T(15;17)), (PROMYELOCYTIC LEUKEMIA/RETINOIC ACID
RECEPTOR ALPHA) (EG, PROMYELOCYTIC LEUKEMIA) TRANSLOCATION
ANALYSIS; SINGLE BREAKPOINT (EG, INTRON 3, INTRON 6 OR EXON 6),
QUALITATIVE OR QUANTITATIVE
81317 PMS2 (POSTMEIOTIC SEGREGATION INCREASED 2 [S. CEREVISIAE]) (EG,
HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME)
GENE ANALYSIS; FULL SEQUENCE ANALYSIS
81318 PMS2 (POSTMEIOTIC SEGREGATION INCREASED 2 [S. CEREVISIAE]) (EG,
HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME)
GENE ANALYSIS; KNOWN FAMILIAL VARIANTS ANALYSIS
81319 PMS2 (POSTMEIOTIC SEGREGATION INCREASED 2 [S. CEREVISIAE]) (EG,
HEREDITARY NON-POLYPOSIS COLORECTAL CANCER, LYNCH SYNDROME)
GENE ANALYSIS; DUPLICATION/DELETION VARIANTS
81321 PTEN (PHOSPHATASE AND TENSIN HOMOLOG) (EG, COWDEN SYNDROME,
PTEN HAMARTOMA TUMOR SYNDROME) GENE ANALYSIS; FULL SEQUENCE
ANALYSIS
81322 PTEN (PHOSPHATASE AND TENSIN HOMOLOG) (EG, COWDEN SYNDROME,
PTEN HAMARTOMA TUMOR SYNDROME) GENE ANALYSIS; KNOWN FAMILIAL
VARIANT
81323 PTEN (PHOSPHATASE AND TENSIN HOMOLOG) (EG, COWDEN SYNDROME,
PTEN HAMARTOMA TUMOR SYNDROME) GENE ANALYSIS;
DUPLICATION/DELETION VARIANT
81340 TRB@ (T CELL ANTIGEN RECEPTOR, BETA) (EG, LEUKEMIA AND LYMPHOMA),
GENE REARRANGEMENT ANALYSIS TO DETECT ABNORMAL CLONAL
POPULATION(S); USING AMPLIFICATION METHODOLOGY (EG, POLYMERASE
CHAIN REACTION)
81341 TRB@ (T CELL ANTIGEN RECEPTOR, BETA) (EG, LEUKEMIA AND LYMPHOMA),
GENE REARRANGEMENT ANALYSIS TO DETECT ABNORMAL CLONAL
POPULATION(S); USING DIRECT PROBE METHODOLOGY (EG, SOUTHERN BLOT)
81342 TRG@ (T CELL ANTIGEN RECEPTOR, GAMMA) (EG, LEUKEMIA AND LYMPHOMA),
GENE REARRANGEMENT ANALYSIS, EVALUATION TO DETECT ABNORMAL
CLONAL POPULATION(S)
81400 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 1 (EG, IDENTIFICATION OF
SINGLE GERMLINE VARIANT [EG, SNP] BY TECHNIQUES SUCH AS RESTRICTION
ENZYME DIGESTION OR MELT CURVE ANALYSIS)
81401 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 2 (EG, 2-10 SNPS, 1
METHYLATED VARIANT, OR 1 SOMATIC VARIANT [TYPICALLY USING
NONSEQUENCING TARGET VARIANT ANALYSIS], OR DETECTION OF A DYNAMIC
MUTATION DISORDER/TRIPLET REPEAT)
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 5 of 17)
Data Source: Local Coverage Determination for Molecular
Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
81402 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 3 (EG, >10 SNPS, 2-10
METHYLATED VARIANTS, OR 2-10 SOMATIC VARIANTS [TYPICALLY USING NONSEQUENCING TARGET VARIANT ANALYSIS], IMMUNOGLOBULIN AND T-CELL
RECEPTOR GENE REARRANGMENTS, DUPLICATION/DELETION VARIANTS OF 1
EXON, LOSS OF HETEROZYGOSITY [LOH], UNIPARENTAL DISOMY [UPD])
81403 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 4 (EG, ANALYSIS OF SINGLE
EXON BY DNA SEQUENCE ANALYSIS, ANALYSIS OF >10 AMPLICONS USING
MULTIPLEX PCR IN 2 OR MORE INDEPENDENT REACTIONS, MUTATION
SCANNING OR DUPLICATION/DELETION VARIANTS OF 2-5 EXONS)
81404 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 5 (EG, ANALYSIS OF 2-5 EXONS
BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR
DUPLICATION/DELETION VARIANTS OF 6-10 EXONS, OR CHARACTERIZATION OF
A DYNAMIC MUTATION DISORDER/TRIPLET REPEAT BY SOUTHERN BLOT
ANALYSIS)
81405 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 6 (EG, ANALYSIS OF 6-10 EXONS
BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR
DUPLICATION/DELETION VARIANTS OF 11-25 EXONS)
81406 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 7 (EG, ANALYSIS OF 11-25
EXONS BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR
DUPLICATION/DELETION VARIANTS OF 26-50 EXONS, CYTOGENOMIC ARRAY
ANALYSIS FOR NEOPLASIA)
81479 UNLISTED MOLECULAR PATHOLOGY PROCEDURE
Group 3 Paragraph:
TIER 1 NON-COVERED MOLECULAR PATHOLOGY PROCEDURES
Genetic testing procedures submitted under the following CPT codes are unlikely to
impact therapeutic decision-making in the clinical management of the patient and will
be denied automatically as not medically necessary:
81161 DMD (DYSTROPHIN) (EG, DUCHENNE/BECKER MUSCULAR DYSTROPHY)
DELETION ANALYSIS, AND DUPLICATION ANALYSIS, IF PERFORMED
81200 ASPA (ASPARTOACYLASE) (EG, CANAVAN DISEASE) GENE ANALYSIS, COMMON
VARIANTS (EG, E285A, Y231X)
81201 APC (ADENOMATOUS POLYPOSIS COLI) (EG, FAMILIAL ADENOMATOSIS
POLYPOSIS [FAP], ATTENUATED FAP) GENE ANALYSIS; FULL GENE SEQUENCE
81202 APC (ADENOMATOUS POLYPOSIS COLI) (EG, FAMILIAL ADENOMATOSIS
POLYPOSIS [FAP], ATTENUATED FAP) GENE ANALYSIS; KNOWN FAMILIAL
VARIANTS
81203 APC (ADENOMATOUS POLYPOSIS COLI) (EG, FAMILIAL ADENOMATOSIS
POLYPOSIS [FAP], ATTENUATED FAP) GENE ANALYSIS; DUPLICATION/DELETION
VARIANTS
81205 BCKDHB (BRANCHED-CHAIN KETO ACID DEHYDROGENASE E1, BETA
POLYPEPTIDE) (EG, MAPLE SYRUP URINE DISEASE) GENE ANALYSIS, COMMON
VARIANTS (EG, R183P, G278S, E422X)
81209 BLM (BLOOM SYNDROME, RECQ HELICASE-LIKE) (EG, BLOOM SYNDROME)
GENE ANALYSIS, 2281DEL6INS7 VARIANT
81219 CALR (CALRETICULIN) (EG, MYELOPROLIFERATIVE DISORDERS), GENE
ANALYSIS, COMMON VARIANTS IN EXON 9
81220 CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR) (EG,
CYSTIC FIBROSIS) GENE ANALYSIS; COMMON VARIANTS (EG, ACMG/ACOG
GUIDELINES)
81221 CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR) (EG,
CYSTIC FIBROSIS) GENE ANALYSIS; KNOWN FAMILIAL VARIANTS
81222 CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR) (EG,
CYSTIC FIBROSIS) GENE ANALYSIS; DUPLICATION/DELETION VARIANTS
81223 CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR) (EG,
CYSTIC FIBROSIS) GENE ANALYSIS; FULL GENE SEQUENCE
81224 CFTR (CYSTIC FIBROSIS TRANSMEMBRANE CONDUCTANCE REGULATOR) (EG,
CYSTIC FIBROSIS) GENE ANALYSIS; INTRON 8 POLY-T ANALYSIS (EG, MALE
INFERTILITY)
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 6 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
81227 CYP2C9 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C, POLYPEPTIDE 9) (EG,
DRUG METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG, *2, *3, *5, *6)
81228 CYTOGENOMIC CONSTITUTIONAL (GENOME-WIDE) MICROARRAY ANALYSIS;
INTERROGATION OF GENOMIC REGIONS FOR COPY NUMBER VARIANTS (EG,
BACTERIAL ARTIFICIAL CHROMOSOME [BAC] OR OLIGO-BASED COMPARATIVE
GENOMIC HYBRIDIZATION [CGH] MICROARRAY ANALYSIS)
81229 CYTOGENOMIC CONSTITUTIONAL (GENOME-WIDE) MICROARRAY ANALYSIS;
INTERROGATION OF GENOMIC REGIONS FOR COPY NUMBER AND SINGLE
NUCLEOTIDE POLYMORPHISM (SNP) VARIANTS FOR CHROMOSOMAL
ABNORMALITIES
81240 F2 (PROTHROMBIN, COAGULATION FACTOR II) (EG, HEREDITARY
HYPERCOAGULABILITY) GENE ANALYSIS, 20210G>A VARIANT
81241 F5 (COAGULATION FACTOR V) (EG, HEREDITARY HYPERCOAGULABILITY) GENE
ANALYSIS, LEIDEN VARIANT
81242 FANCC (FANCONI ANEMIA, COMPLEMENTATION GROUP C) (EG, FANCONI
ANEMIA, TYPE C) GENE ANALYSIS, COMMON VARIANT (EG, IVS4+4A>T)
81243 FMR1 (FRAGILE X MENTAL RETARDATION 1) (EG, FRAGILE X MENTAL
RETARDATION) GENE ANALYSIS; EVALUATION TO DETECT ABNORMAL (EG,
EXPANDED) ALLELES
81244 FMR1 (FRAGILE X MENTAL RETARDATION 1) (EG, FRAGILE X MENTAL
RETARDATION) GENE ANALYSIS; CHARACTERIZATION OF ALLELES (EG,
EXPANDED SIZE AND METHYLATION STATUS)
81250 G6PC (GLUCOSE-6-PHOSPHATASE, CATALYTIC SUBUNIT) (EG, GLYCOGEN
STORAGE DISEASE, TYPE 1A, VON GIERKE DISEASE) GENE ANALYSIS,
COMMON VARIANTS (EG, R83C, Q347X)
81251 GBA (GLUCOSIDASE, BETA, ACID) (EG, GAUCHER DISEASE) GENE ANALYSIS,
COMMON VARIANTS (EG, N370S, 84GG, L444P, IVS2+1G>A)
81252 GJB2 (GAP JUNCTION PROTEIN, BETA 2, 26KDA, CONNEXIN 26) (EG,
NONSYNDROMIC HEARING LOSS) GENE ANALYSIS; FULL GENE SEQUENCE
81252 GJB2 (GAP JUNCTION PROTEIN, BETA 2, 26KDA, CONNEXIN 26) (EG,
NONSYNDROMIC HEARING LOSS) GENE ANALYSIS; FULL GENE SEQUENCE
81253 GJB2 (GAP JUNCTION PROTEIN, BETA 2, 26KDA, CONNEXIN 26) (EG,
NONSYNDROMIC HEARING LOSS) GENE ANALYSIS; KNOWN FAMILIAL VARIANTS
81254 GJB6 (GAP JUNCTION PROTEIN, BETA 6, 30KDA, CONNEXIN 30) (EG,
NONSYNDROMIC HEARING LOSS) GENE ANALYSIS, COMMON VARIANTS (EG,
309KB [DEL(GJB6-D13S1830)] AND 232KB [DEL(GJB6-D13S1854)])
81255 HEXA (HEXOSAMINIDASE A [ALPHA POLYPEPTIDE]) (EG, TAY-SACHS DISEASE)
GENE ANALYSIS, COMMON VARIANTS (EG, 1278INSTATC, 1421+1G>C, G269S)
81257 HBA1/HBA2 (ALPHA GLOBIN 1 AND ALPHA GLOBIN 2) (EG, ALPHA THALASSEMIA,
HB BART HYDROPS FETALIS SYNDROME, HBH DISEASE), GENE ANALYSIS, FOR
COMMON DELETIONS OR VARIANT (EG, SOUTHEAST ASIAN, THAI, FILIPINO,
MEDITERRANEAN, ALPHA3.7, ALPHA4.2, ALPHA20.5, AND CONSTANT SPRING)
81260 IKBKAP (INHIBITOR OF KAPPA LIGHT POLYPEPTIDE GENE ENHANCER IN BCELLS, KINASE COMPLEX-ASSOCIATED PROTEIN) (EG, FAMILIAL
DYSAUTONOMIA) GENE ANALYSIS, COMMON VARIANTS (EG, 2507+6T>C, R696P)
81280 LONG QT SYNDROME GENE ANALYSES (EG, KCNQ1, KCNH2, SCN5A, KCNE1,
KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP, SNTA1, AND ANK2); FULL
SEQUENCE ANALYSIS
81281 LONG QT SYNDROME GENE ANALYSES (EG, KCNQ1, KCNH2, SCN5A, KCNE1,
KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP, SNTA1, AND ANK2); KNOWN
FAMILIAL SEQUENCE VARIANT
81282 LONG QT SYNDROME GENE ANALYSES (EG, KCNQ1, KCNH2, SCN5A, KCNE1,
KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP, SNTA1, AND ANK2);
DUPLICATION/DELETION VARIANTS
81290 MCOLN1 (MUCOLIPIN 1) (EG, MUCOLIPIDOSIS, TYPE IV) GENE ANALYSIS,
COMMON VARIANTS (EG, IVS3-2A>G, DEL6.4KB)
81302 MECP2 (METHYL CPG BINDING PROTEIN 2) (EG, RETT SYNDROME) GENE
ANALYSIS; FULL SEQUENCE ANALYSIS
81303 MECP2 (METHYL CPG BINDING PROTEIN 2) (EG, RETT SYNDROME) GENE
ANALYSIS; KNOWN FAMILIAL VARIANT
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 7 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
81304 MECP2 (METHYL CPG BINDING PROTEIN 2) (EG, RETT SYNDROME) GENE
ANALYSIS; DUPLICATION/DELETION VARIANTS
81324 PMP22 (PERIPHERAL MYELIN PROTEIN 22) (EG, CHARCOT-MARIE-TOOTH,
HEREDITARY NEUROPATHY WITH LIABILITY TO PRESSURE PALSIES) GENE
ANALYSIS; DUPLICATION/DELETION ANALYSIS
81325 PMP22 (PERIPHERAL MYELIN PROTEIN 22) (EG, CHARCOT-MARIE-TOOTH,
HEREDITARY NEUROPATHY WITH LIABILITY TO PRESSURE PALSIES) GENE
ANALYSIS; FULL SEQUENCE ANALYSIS
81326 PMP22 (PERIPHERAL MYELIN PROTEIN 22) (EG, CHARCOT-MARIE-TOOTH,
HEREDITARY NEUROPATHY WITH LIABILITY TO PRESSURE PALSIES) GENE
ANALYSIS; KNOWN FAMILIAL VARIANT
81330 SMPD1(SPHINGOMYELIN PHOSPHODIESTERASE 1, ACID LYSOSOMAL) (EG,
NIEMANN-PICK DISEASE, TYPE A) GENE ANALYSIS, COMMON VARIANTS (EG,
R496L, L302P, FSP330)
81331 SNRPN/UBE3A (SMALL NUCLEAR RIBONUCLEOPROTEIN POLYPEPTIDE N
AND
UBIQUITIN PROTEIN LIGASE E3A) (EG, PRADER-WILLI SYNDROME AND/OR
ANGELMAN SYNDROME), METHYLATION ANALYSIS
81350 UGT1A1 (UDP GLUCURONOSYLTRANSFERASE 1 FAMILY, POLYPEPTIDE A1)
(EG, IRINOTECAN METABOLISM), GENE ANALYSIS, COMMON VARIANTS (EG,
*28, *36, *37)
81355 VKORC1 (VITAMIN K EPOXIDE REDUCTASE COMPLEX, SUBUNIT 1) (EG,
WARFARIN METABOLISM), GENE ANALYSIS, COMMON VARIANT(S) (EG, 1639G>A, C.173+1000C>T)
Group 4 Paragraph: TIER 2 NON-COVERED MOLECULAR PATHOLOGY
PROCEDURES
Genetic testing procedures submitted under the following CPT codes are unlikely
to impact therapeutic decision-making in the clinical management of the patient
and will be denied automatically as not medically necessary:
Group 4 Codes:
81407 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 8 (EG, ANALYSIS OF 26-50 EXONS
BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR DUPLICATION/DELETION
VARIANTS OF >50 EXONS, SEQUENCE ANALSYSIS OF MULTIPLE GENES ON ONE
PLATFORM)
81408 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 9 (EG, ANALYSIS OF >50 EXONS IN
A SINGLE GENE BY DNA SEQUENCE ANALYSIS)
Group 5 Paragraph: NON-COVERED GENOMIC SEQUENCING PROCEDURES AND
OTHER MOLECULAR ANALYTE ASSAYS
Genetic testing procedures submitted under the following CPT codes will be
denied automatically as not medically necessary:
81410 - 81440 AORTIC DYSFUNCTION OR DILATION (EG, MARFAN SYNDROME, LOEYS
DIETZ SYNDROME, EHLER DANLOS SYNDROME TYPE IV, ARTERIAL TORTUOSITY
SYNDROME); GENOMIC SEQUENCE ANALYSIS PANEL, MUST INCLUDE SEQUENCING OF
AT LEAST 9 GENES, INCLUDING FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2,
SLC2A10, SMAD3, AND MYLK - NUCLEAR ENCODED MITOCHONDRIAL GENES (EG,
NEUROLOGIC OR MYOPATHIC PHENOTYPES), GENOMIC SEQUENCE PANEL, MUST
INCLUDE ANALYSIS OF AT LEAST 100 GENES, INCLUDING BCS1L, C10ORF2, COQ2,
COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4,
SUCLA2, SUCLG1, TAZ, TK2, AND TYMP
81450 - 81471 TARGETED GENOMIC SEQUENCE ANALYSIS PANEL, HEMATOLYMPHOID
NEOPLASM OR DISORDER, DNA ANALYSIS, AND RNA ANALYSIS WHEN PERFORMED, 5-50
GENES (EG, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS,
NPM1, NOTCH1), INTERROGATION FOR SEQUENCE VARIANTS, AND COPY NUMBER
VARIANTS OR REARRANGEMENTS, OR ISOFORM EXPRESSION OR MRNA EXPRESSION
LEVELS, IF PERFORMED - X-LINKED INTELLECTUAL DISABILITY (XLID) (EG, SYNDROMIC
AND NON-SYNDROMIC XLID); DUPLICATION/DELETION GENE ANALYSIS, MUST INCLUDE
ANALYSIS OF AT LEAST 60 GENES, INCLUDING ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1,
IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, AND SLC16A2
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (pg. 8 of 17)
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
ICD-10 Codes that Support Medical Necessity
TIER 1 COVERED MOLECULAR PATHOLOGY PROCEDURES
Limited coverage may be provided for the genetic tests, submitted under the following
CPT codes:
Note: Please refer to the Indications and Limitations of Coverage section and the
ICD-10-CM diagnosis to CPT procedure groupings. Not all procedure codes have
related diagnosis codes listed.
Group 1 Paragraph: CPT code 81170 is considered medically necessary for the
following ICD-10-CM codes
CPT CODE 81170 ABL1 (ABLPROTO-ONCOGENE 1, NON-RECEPTOR
TYROSINE KINASE) (EG, ACQUIRED IMATINIB TYROSINE KINASE INHIBITOR
RESISTANCE), GENE ANALYSIS, VARIANTS IN THE KINASE DOMAIN
C91.00 Acute lymphoblastic leukemia not having achieved remission
C91.01 Acute lymphoblastic leukemia, in remission
C91.02 Acute lymphoblastic leukemia, in relapse
C91.10 Chronic lymphocytic leukemia of B-cell type not having achieved remission
C91.11 Chronic lymphocytic leukemia of B-cell type in remission
C91.12 Chronic lymphocytic leukemia of B-cell type in relapse
Group 2 Paragraph: CPT codes 81206, 81207, and 81208 (BCR/ABL) are
considered medically necessary for the following ICD-10-CM codes:
CPT CODE 81206 BCR/ABL1 (T(9;22)) (EG, CHRONIC MYELOGENOUS
LEUKEMIA) TRANSLOCATION ANALYSIS; MAJOR BREAKPOINT, QUALITATIVE
OR QUANTITATIVE
CPT CODE 81207 BCR/ABL 1 (T(9;22)) (EG, CHRONIC MYELOGENOUS
LEUKEMIA) TRANSLOCATION ANALYSIS; MINOR BREAKPOINT, QUALITATIVE
OR QUANTITATIVE
CPT CODE 81208 BCR/ABL 1 (T(9;22)) (EG, CHRONIC MYELOGENOUS
LEUKEMIA) TRANSLOCATION ANALYSIS; OTHER BREAKPOINT, QUALITATIVE
OR QUANTITATIVE
C91.00 - C91.02 Acute lymphoblastic leukemia not having achieved remission –
Acute lymphoblastic leukemia, in relapse
C92.10 - C92.12 Chronic myeloid leukemia, BCR/ABL-positive, not having achieved
remission - Chronic myeloid leukemia, BCR/ABL-positive, in
relapse
C92.20 - C92.22 Atypical chronic myeloid leukemia, BCR/ABL-negative, not having
achieved remission - Atypical chronic myeloid leukemia,
BCR/ABL- negative, in relapse
C92.90 - C92.92 Myeloid leukemia, unspecified, not having achieved remission Myeloid leukemia, unspecified in relapse
Group 3 Paragraph: CPT code 81210 (BRAF) is considered medically
necessary for the following ICD-10-CM codes:
CPT CODE 81210 BRAF (B-RAF PROTO-ONCOGENE, SERINE/THREONINE
KINASE) (EG, COLON CANCER, MELANOMA), GENE ANALYSIS, V600
VARIANT(S)
C33 - C34.92
Malignant neoplasm of trachea - Malignant neoplasm of
unspecified part of left bronchus or lung
C43.0 - C43.9
Malignant melanoma of lip - Malignant melanoma of skin,
unspecified
C91.40 - C91.42 Hairy cell leukemia not having achieved remission - Hairy cell
leukemia, in relapse
D03.0 - D03.9
Melanoma in situ of lip - Melanoma in situ, unspecified
Z85.820
Personal history of malignant melanoma of skin
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (pg. 9 of 17)
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
Group 4 Paragraph: CPT Code 81218 (CEBPA) is considered medically
necessary for the following ICD-10-CM codes:
CPT CODE 81218 CEBPA (CCAAT/ENHANCER BINDING PROTEIN [C/EBP],
ALPHA) (EG, ACUTE MYELOID LEUKEMIA), GENE ANALYSIS, FULL GENE
SEQUENCE
C91.00 - C91.02 Acute lymphoblastic leukemia not having achieved remission –
Acute lymphoblastic leukemia, in relapse
C92.60 - C92.62 Acute myeloid leukemia with 11q23-abnormality not having
achieved remission - Acute myeloid leukemia with 11q23abnormality in relapse
Group 5 Paragraph: CPT code 81225 (CYP2C19) is considered medically
necessary for the following ICD-10-CM codes:
CPT CODE 81225 CYP2C19 (CYTOCHROME P450, FAMILY 2, SUBFAMILY C,
POLYPEPTIDE 19) (EG, DRUG METABOLISM), GENE ANALYSIS, COMMON
VARIANTS (EG, *2, *3, *4, *8, *17)
I20.0
Unstable angina
I20.1
Angina pectoris with documented spasm
I20.8
Other forms of angina pectoris
I20.9
Angina pectoris, unspecified
I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery
I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of
inferior wall
I21.29 ST elevation (STEMI) myocardial infarction involving other sites
I21.3
ST elevation (STEMI) myocardial infarction of unspecified site
I21.4
Non-ST elevation (NSTEMI) myocardial infarction
I24.0
Acute coronary thrombosis not resulting in myocardial infarction
I24.1
Dressler's syndrome
I24.8
Other forms of acute ischemic heart disease
I24.9
Acute ischemic heart disease, unspecified
I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina
pectoris
I25.118 Atherosclerotic heart disease of native coronary artery with other forms of
angina pectoris
I25.119 Atherosclerotic heart disease of native coronary artery with unspecified
angina pectoris
I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, with
unstable angina pectoris
I25.701 Atherosclerosis of coronary artery bypass graft(s), unspecified, with angina
pectoris with documented spasm
I25.708 Atherosclerosis of coronary artery bypass graft(s), unspecified, with other
forms of angina pectoris
I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s) with
unstable angina pectoris
I25.711 Atherosclerosis of autologous vein coronary artery bypass graft(s) with
angina pectoris with documented spasm
I25.718 Atherosclerosis of autologous vein coronary artery bypass graft(s) with
other forms of angina pectoris
I25.719 - I25.721 Atherosclerosis of autologous vein coronary artery bypass graft(s)
with unspecified angina pectoris - Atherosclerosis of autologous artery
coronary artery bypass graft(s) with angina pectoris with documented
spasm
I25.728 - I25.731 Atherosclerosis of autologous artery coronary artery bypass
graft(s) with other forms of angina pectoris - Atherosclerosis of
nonautologous biological coronary artery bypass graft(s) with angina
pectoris with documented spasm
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 10 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
I25.738 Atherosclerosis of nonautologous biological coronary artery bypass graft(s)
with other forms of angina pectoris
I25.739 Atherosclerosis of nonautologous biological coronary artery bypass graft(s)
with unspecified angina pectoris
I25.750 Atherosclerosis of native coronary artery of transplanted heart with
unstable angina
I25.751 Atherosclerosis of native coronary artery of transplanted heart with angina
pectoris with documented spasm
I25.758 - I25.761 Atherosclerosis of native coronary artery of transplanted heart
with other forms of angina pectoris - Atherosclerosis of bypass graft of
coronary artery of transplanted heart with angina pectoris with documented
spasm
I25.769 Atherosclerosis of bypass graft of coronary artery of transplanted heart with
unspecified angina pectoris
I25.790 Atherosclerosis of other coronary artery bypass graft(s) with unstable
angina pectoris
I25.791 Atherosclerosis of other coronary artery bypass graft(s) with angina pectoris
with documented spasm
I25.798 Atherosclerosis of other coronary artery bypass graft(s) with other forms of
angina pectoris
I25.799 Atherosclerosis of other coronary artery bypass graft(s) with unspecified
angina pectoris
Group 6 Paragraph: CPT code 81226 (CYP2d6) is considered medically
necessary for the following ICD-10-CM codes:
CPT CODE 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)
E75.22 Gaucher disease
G10
Huntington's disease
Group 7 Paragraph: CPT code 81235 (EGFR) is considered medically
necessary for the following ICD-10-CM codes:
CPT CODE 81235 EGFR (EPIDERMAL GROWTH FACTOR RECEPTOR) (EG,
NON-SMALL CELL LUNG CANCER) GENE ANALYSIS, COMMON VARIANTS
(EG, EXON 19 LREA DELETION, L858R, T790M, G719A, G719S, L861Q)
C33 - C34.92 Malignant neoplasm of trachea - Malignant neoplasm of unspecified
part of left bronchus or lung
Group 8 Paragraph: CPT code 81245, 81246 (FLT3) are considered medically
necessary for the following ICD-10-CM codes:
CPT CODE 81245 FLT3 (FMS-RELATED TYROSINE KINASE 3) (EG, ACUTE
MYELOID LEUKEMIA), GENE ANALYSIS; INTERNAL TANDEM DUPLICATION
(ITD) VARIANTS (IE, EXONS 14, 15)
CPT CODE 81246 FLT3 (FMS-RELATED TYROSINE KINASE 3) (EG, ACUTE
MYELOID LEUKEMIA), GENE ANALYSIS; TYROSINE KINASE DOMAIN (TKD)
VARIANTS (EG, D835, I836)
C92.40 - C92.42 Acute promyelocytic leukemia, not having achieved remission –
Acute promyelocytic leukemia, in relapse
C92.50 - C92.52 Acute myelomonocytic leukemia, not having achieved remission –
Acute myelomonocytic leukemia, in relapse
C92.60 - C92.62 Acute myeloid leukemia with 11q23-abnormality not having
achieved remission - Acute myeloid leukemia with 11q23abnormality in relapse
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 11 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
Group 9 Paragraph: CPT code 81256 (HFE) is considered medically necessary
the following ICD-10-CM codes:
CPT CODE 81256 HFE (HEMOCHROMATOSIS) (EG, HEREDITARY
HEMOCHROMATOSIS) GENE ANALYSIS, COMMON VARIANTS (EG, C282Y,
H63D)
E83.10 Disorder of iron metabolism, unspecified
E83.110 Hereditary hemochromatosis
E83.118 Other hemochromatosis
E83.119 Hemochromatosis, unspecified
E83.19 Other disorders of iron metabolism
Group 10 Paragraph: CPT codes 81261-81264 (IGH) are considered medically
necessary for the following ICD-10-CM codes:
CPT CCODE 81261 IGH@ (IMMUNOGLOBULIN HEAVY CHAIN LOCUS) (EG,
LEUKEMIAS AND LYMPHOMAS, B-CELL), GENE REARRANGEMENT ANALYSIS
TO DETECT ABNORMAL CLONAL POPULATION(S); AMPLIFIED METHODOLOGY
(EG, POLYMERASE CHAIN REACTION)
CPT CODE 81262 IGH@ (IMMUNOGLOBULIN HEAVY CHAIN LOCUS) (EG,
LEUKEMIAS AND LYMPHOMAS, B-CELL), GENE REARRANGEMENT ANALYSIS
TO DETECT ABNORMAL CLONAL POPULATION(S); DIRECT PROBE
METHODOLOGY (EG, SOUTHERN BLOT)
CPT CODE 81263 IGH@ (IMMUNOGLOBULIN HEAVY CHAIN LOCUS) (EG,
LEUKEMIA AND LYMPHOMA, B-CELL), VARIABLE REGION SOMATIC MUTATION
ANALYSIS
CPT CODE 81264 IGK@ (IMMUNOGLOBULIN KAPPA LIGHT CHAIN LOCUS) (EG,
LEUKEMIA AND LYMPHOMA, B-CELL), GENE REARRANGEMENT ANALYSIS,
EVALUATION TO DETECT ABNORMAL CLONAL POPULATION(S)
C82.00 - C83.99 - Follicular lymphoma grade I, unspecified site - Non-follicular
(diffuse) lymphoma, unspecified, extranodal and solid organ sites
C85.20 - C85.29 - Mediastinal (thymic) large B-cell
lymphoma, unspecified site - Mediastinal (thymic) large B-cell lymphoma,
extranodal and solid organ sites
C91.00 - C91.32 - Acute lymphoblastic leukemia not having
achieved remission - Prolymphocytic leukemia of B-cell type, in relapse
C91.50 - C91.62 - Adult T-cell lymphoma/leukemia (HTLV1- associated) not having achieved remission - Prolymphocytic leukemia of
T- cell type, in relapse
C91.A0 - C93.92 - Mature B-cell leukemia Burkitt-type not
having achieved remission - Monocytic leukemia, unspecified in relapse
C95.00 - C95.92 - Acute leukemia of unspecified cell type
not having achieved remission - Leukemia, unspecified, in relapse
D72.828 Other elevated white blood cell count
D72.89 Other specified disorders of white blood cells
Group 11 Paragraph: CPT code 81270 (JAK2) is considered medically
necessary for the following ICD-10-CM codes:
CPT CODE 81270 JAK2 (JANUS KINASE 2) (EG, MYELOPROLIFERATIVE
DISORDER) GENE ANALYSIS, P.VAL617PHE (V617F) VARIANT
C88.8 Other malignant immunoproliferative diseases
C94.40 - C94.42 - Opens in a new window Acute panmyelosis with myelofibrosis not
having achieved remission - Acute panmyelosis with myelofibrosis, in
relapse
C94.6 Myelodysplastic disease, not classified
D45
Polycythemia vera
D46.0 Refractory anemia without ring sideroblasts, so stated
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 12 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
CPT CODE 81273 KIT (V-KIT HARDY-ZUCKERMAN 4 FELINE SARCOMA VIRAL
ONCOGENE HOMOLOG) (EG, MASTOCYTOSIS), GENE ANALYSIS, D816
D46.1 Refractory anemia with ring sideroblasts
VARIANT(S)
D46.20 Refractory anemia with excess of blasts, unspecified
C43.0 - C43.9 - Malignant melanoma of lip - Malignant melanoma of skin, unspecified
D46.21 Refractory anemia with excess of blasts 1
C49.A0 - C49.A9 - Gastrointestinal stromal tumor, unspecified site - Gastrointestinal
D46.A Refractory cytopenia with multilineage dysplasia
stromal tumor of other sites
D46.B Refractory cytopenia with multilineage dysplasia and ring sideroblasts
C92.00 - C92.02 - Acute myeloblastic leukemia, not having achieved remission D46.C Myelodysplastic syndrome with isolated del(5q) chromosomal abnormality
Acute myeloblastic leukemia, in relapse
D46.4
Refractory anemia, unspecified
C92.40 - C92.42 - promyelocytic leukemia, not having achieved remission - Acute
D46.Z Other myelodysplastic syndromes
promyelocytic leukemia, in relapse
D46.9
Myelodysplastic syndrome, unspecified
C92.50 - C92.52 - Acute myelomonocytic leukemia, not having achieved remission D47.1
Chronic myeloproliferative disease
Acute myelomonocytic leukemia, in relapse C96.2* Malignant mast cell
D47.3
Essential (hemorrhagic) thrombocythemia
tumor
D47.Z9 Other specified neoplasms of uncertain behavior of lymphoid,
D03.0 - D03.9 - Melanoma in situ of lip - Melanoma in situ, unspecified
hematopoietic and related tissue
D47.0* Histiocytic and mast cell tumors of uncertain behavior
D47.9
Neoplasm of uncertain behavior of lymphoid, hematopoietic and related
D48.1 Neoplasm of uncertain behavior of connective and other soft tissue
tissue, unspecified
Z85.820 Personal history of malignant melanoma of skin
Group 12 Paragraph:
Group 13 Paragraph: CPT code 81275 and 81276 (KRAS) are considered
CPT code 81272 (KIT) is considered medically necessary for the following
medically necessary for the following ICD-10-CM codes:
ICD-10-CM codes:
CPT CODE 81275 KRAS (KIRSTEN RAT SARCOMA VIRAL ONCOGENE
CPT code 81273 (KIT) is considered medically necessary only for the
HOMOLOG) (EG, CARCINOMA) GENE ANALYSIS; VARIANTS IN EXON 2 (EG,
diagnosis of mastocytosis*.
CODONS 12 AND 13)
CPT CODE 81272 KIT (V-KIT HARDY-ZUCKERMAN 4 FELINE SARCOMA VIRAL
CPT CODE 81276 KRAS (KIRSTEN RAT SARCOMA VIRAL ONCOGENE
ONCOGENE HOMOLOG) (EG, GASTROINTESTINAL STROMAL TUMOR [GIST],
HOMOLOG) (EG, CARCINOMA) GENE ANALYSIS; ADDITIONAL VARIANT(S) (EG,
ACUTE MYELOID LEUKEMIA, MELANOMA), GENE ANALYSIS, TARGETED
CODON 61, CODON 146
SEQUENCE ANALYSIS (EG, EXONS 8, 11, 13, 17, 18)
C17.0 - C17.9 Malignant neoplasm of duodenum - Malignant neoplasm of small
intestine, unspecified
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 13 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
C18.0 - C19 - Malignant neoplasm of cecum - Malignant neoplasm of rectosigmoid
junction
C20
Malignant neoplasm of rectum
C21.1
Malignant neoplasm of anal canal
C21.2
Malignant neoplasm of cloacogenic zone
C21.8
Malignant neoplasm of overlapping sites of rectum, anus and anal canal
C33 - C34.92 - Malignant neoplasm of trachea - Malignant neoplasm of unspecified
part of left bronchus or lung
Z85.038 Personal history of other malignant neoplasm of large intestine
Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid
junction, and anus
Group 14 Paragraph: CPT Code 81311 (NRAS) is considered medically
necessary for the following ICD-10-CM codes
CPT CODE 81311 NRAS (NEUROBLASTOMA RAS VIRAL [V-RAS] ONCOGENE
HOMOLOG) (EG, COLORECTAL CARCINOMA), GENE ANALYSIS, VARIANTS IN
EXON 2 (EG, CODONS 12 AND 13) AND EXON 3 (EG, CODON 61)
C17.0 - C17.9 - Malignant neoplasm of duodenum - Malignant neoplasm of small
intestine, unspecified
C18.0 - C19 - Malignant neoplasm of cecum - Malignant neoplasm of rectosigmoid
junction
C20
Malignant neoplasm of rectum
C21.1 Malignant neoplasm of anal canal
C21.2 Malignant neoplasm of cloacogenic zone
C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal
Z85.038 Personal history of other malignant neoplasm of large intestine
Z85.048 Personal history of other malignant neoplasm of rectum, rectosigmoid
junction, and anus
Group 15 Paragraph: CPT Code 81314 (PDGFRA only) is considered medically
necessary for the following ICD-10-CM codes:
CPT CODE 81314 PDGFRA (PLATELET-DERIVED GROWTH FACTOR
RECEPTOR, ALPHA POLYPEPTIDE) (EG, GASTROINTESTINAL STROMAL
TUMOR [GIST]), GENE ANALYSIS, TARGETED SEQUENCE ANALYSIS (EG,
EXONS 12, 18)
C92.10 - C92.12 - Chronic myeloid leukemia, BCR/ABL-positive, not having
achieved remission - Chronic myeloid leukemia, BCR/ABL-positive, in
relapse
C93.10 - C93.12 - Chronic myelomonocytic leukemia not having achieved remission
- Chronic myelomonocytic leukemia, in relapse
D48.1 Neoplasm of uncertain behavior of connective and other soft tissue
Group 16 Paragraph: CPT code 81401 DEK/NUP214 (t(6;9)) is considered
medically necessary for patients who have AML.
CPT code 81401 IGH@BCL2 (t(14:18)) is considered medically necessary for
patients who have Non- Hodgkin’s Lymphoma.
Group 16 Medical Necessity ICD-10 Codes Asterisk Explanation: **CPT code
81401 IGH@BCL2 (t(14:18)) only
CPT CODE 81401 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 2 (EG, 2-10
SNPS, 1 METHYLATED VARIANT, OR 1 SOMATIC VARIANT [TYPICALLY USING
NONSEQUENCING TARGET VARIANT ANALYSIS], OR DETECTION OF A
DYNAMIC MUTATION DISORDER/TRIPLET REPEAT)
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 14 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
C85.10 - C85.99* - Unspecified B-cell lymphoma, unspecified site - Non-Hodgkin
lymphoma, unspecified, extranodal and solid organ sites
C92.00 - C92.02 - Acute myeloblastic leukemia, not having achieved remission –
Acute myeloblastic leukemia, in relapse
C92.40 - C92.42 - Acute promyelocytic leukemia, not having achieved remission –
Acute promyelocytic leukemia, in relapse
C92.50 - C92.52 - Acute myelomonocytic leukemia, not having achieved remission –
Acute myelomonocytic leukemia, in relapse
Group 18 Paragraph: CPT code 81406 (ATP7B) is considered medically
necessary for the following ICD-10-CM code:
Group 17 Paragraph: CPT codes 81404 and 81405 (RET- Types 2B and 2A) are
considered medically necessary for the following ICD-10-CM codes:
ICD-10 Codes that DO NOT Support Medical Necessity
CPT CODE 81404 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 5 (EG,
ANALYSIS OF 2-5 EXONS BY DNA SEQUENCE ANALYSIS, MUTATION
SCANNING OR DUPLICATION/DELETION VARIANTS OF 6-10 EXONS, OR
CHARACTERIZATION OF A DYNAMIC MUTATION DISORDER/TRIPLET REPEAT
BY SOUTHERN BLOT ANALYSIS)
CPT CODE 81405 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 6 (EG,
ANALYSIS OF 6-10 EXONS BY DNA SEQUENCE ANALYSIS, MUTATION
SCANNING OR DUPLICATION/DELETION VARIANTS OF 11-25 EXONS)
C73
Malignant neoplasm of thyroid gland
C74.10 - C74.12 - Malignant neoplasm of medulla of unspecified adrenal gland Malignant neoplasm of medulla of left adrenal gland
C75.0 Malignant neoplasm of parathyroid gland
D35.1 Benign neoplasm of parathyroid gland
E83.01 Wilson's disease
CPT CODE 81406 MOLECULAR PATHOLOGY PROCEDURE, LEVEL 7 (EG, ANALYSIS
OF 11-25 EXONS BY DNA SEQUENCE ANALYSIS, MUTATION SCANNING OR
DUPLICATION/DELETION VARIANTS OF 26-50 EXONS, CYTOGENOMIC ARRAY
ANALYSIS FOR NEOPLASIA)
E83.01
Wilson's disease
Group 1 Paragraph: The following ICD-10-CM codes are considered noncovered for all molecular pathology procedures:
Z31.430 Encounter of female for testing for genetic disease carrier status for
procreative management
Z31.438 Encounter for other genetic testing of female for procreative management
Z31.440 Encounter of male for testing for genetic disease carrier status for
procreative management
Z31.441 Encounter for testing of male partner of patient with recurrent pregnancy
loss
Z31.448 Encounter for other genetic testing of male for procreative management
Z31.5
Encounter for genetic counseling
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 15 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
TIER 1 AND TIER 2 INDICATIONS AND LIMITATIONS OF COVERAGE
CPT Codes 81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217
BRCA1 and BRCA2 genetic testing is considered medically necessary for a
beneficiary with a personal history of a cancer associated with the BRCA mutation
who meets one or more of the criteria found in the most recent version of the NCCN
guidelines for Genetic/Familial High-Risk Assessment: Breast and Ovarian or other
evidence based guideline addressing genetic testing.
CPT Code 81219
CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common
variants in exon 9 is not covered.
CPT Code 81227 Use only G9143 CYP2C9 and/or VKORC1 Gene Testing for
Warfarin Response- Pharmacogenomic Testing for Warfarin Response, gene
testing on CYP2C9 and/or VKORC1 see NCD 90.1 for coverage information.
CPT Code 81240 and 81241
F2 gene (prothrombin coagulation factor II) and F5 gene (coagulation factor V)
The F2 and F5 genetic tests are not considered to be clinically efficacious; therefore,
testing is not medically necessary.
CPT codes 81265-81268
Chimerism analysis to identify appropriate donors and monitor engraftment success
or disease reoccurrence is considered medically necessary.
CPT code 81265 includes donor and recipient testing and should be reported with
one unit of service. Except in rare cases, this service would only be performed once
per lifetime.
CPT code 81266 describes a service that may be used for two different reasons:
additional births and bone marrow transplant. When used in bone marrow transplants
to report an additional double-cord blood sample, it is a covered service.
Since its use to report multiple births would be atypical for the Medicare population, it
would not be a covered service.
CPT code 81267 is considered medically necessary in patients with diagnoses of
leukemia and lymphomas and should be used post transplantation to confirm
successful engraftment or disease reoccurrence. Although the original donor
specimen may be referenced, an additional 81265 should not be submitted in addition
to the 81267 service. For labs that hold the pre-transplant specimen (81265 and/or
81266) until after the transplant occurs, use 81267 plus 81265 and 81266 if
necessary.
CPT code 81267 may be reported for the findings of the pre and post-transplant
comparison.
CPT code 81268 may be used to report chimerism using a buccal or other germline
tissue specimen from the recipient post-transplantation. For laboratories that hold the
pre-transplant specimen (81265 and/or 81266) until after the transplant occurs, use
81267 plus 81265 and 81266 if necessary.
National Government Services would not expect to see a claim for 81265 pretransplant and an additional 81265 and 81267 post-transplant or a claim for CPT
codes 81265 pre-transplant and an additional claim for 81268.
Note: Although the initial chimerism testing, CPT code 81265, for engraftment is
usually limited to once in a lifetime, National Government Services recognizes special
circumstances may require an additional service and will consider approval on a
case-by-case basis through the appeal process.
CPT Code 81287
MGMT (O-6-methylguanine-DNA methyltransferase) (e.g., glioblastoma multiforme),
methylation analysis) is considered medically necessary in patients with glioblastoma
to guide therapeutic decision making.
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 16 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
CPT Code 81301
Microsatellite instability analysis (e.g., hereditary non-polyposis colorectal cancer,
Lynch syndrome) of markers for mismatch repair deficiency (e.g. BAT25, BAT26),
includes comparison of neoplastic and normal tissue, if performed may be
considered medically necessary in patients with colon cancer to guide therapeutic
decision-making.
CPT Code 81310
NPM1 (nucleophosmin) is considered medically necessary in patients with acute
myeloid leukemia (AML) to guide therapeutic decision making.
CPT Code 81313
PCA3 testing is considered medically necessary in patients ONLY when all biopsies
in previous encounter(s) are negative for prostatic cancer, the subsequent prostate
specific antigen (PSA) is rising, and when the patient or physician wants to avoid
repeat biopsy (“watchful waiting”).
When the physician plans to biopsy the prostate, NGS will consider a PCA3 test as
not medically necessary, and thus, not a covered Medicare benefit. NGS considers
all other indications for PCA3 not reasonable and necessary.
Medical record documentation must indicate the rationale to perform a PCA3 assay.
CPT Codes 81370- 81383
HLA Class I or II typing is considered medically necessary when one of the following
indications is met:
•Transplantation:
◦Standard of care determination of HLA matching for solid organ transplant
(donor/recipient). – Solid organ transplant registries include both serological HLA
testing (e.g., crossmatch) and genomic molecular DNA typing. Family members, or
unrelated living donors or cadaveric donors who donate bone marrow or a solid
organ are HLA tested pre-transplant to determine compatibility with the potential
recipients.
◦Standard of care identification of determination of HLA matching for hematopoietic
stem cell/bone marrow transplantation -allele-level typing will provide clinical
guidance for the HLA-A,B,C Class I and DRB1, DQB1,DPB1, and DQA1 Class II loci
in the average transplant program because it is well established that mismatches at
certain HLA loci between donor-recipients are closely linked to the risk of graft versus
host disease. Potential marrow donors may enroll with a national registry such as the
United States National Marrow Donor Program or the Canadian Blood Services
registry.
•Disease Association:
◦Standard of care testing to diagnose certain HLA related diseases/conditions when
the testing is supported by the clinical literature and is informative for the direct
management of a patient bearing a certain allele(s). It is not expected that more than
one test would be required in a given beneficiary’s lifetime. Possible covered
indications when standard laboratory testing (tissue typing) not adequate:
◦HLA-B*27 for the diagnosis of certain cases of symptomatic patients with presumed
ankylosing spondylitis or related inflammatory disease. HLA-B*27 is covered for
ankylosing spondylitis in cases where other methods of diagnosis would not be
appropriate or have yielded inconclusive results (NCD 190.1).
◦In the work-up of certain patients with an unclear diagnosis of celiac disease and
gluten hypersensitivity usually related to ambiguous standard laboratory results
and/or inconsistent biopsy results (e.g., HLA-DQ2 by HLA-DQB1*02 and of DQ8 by
HLA-DQB1*0302).
•Pharmacogenetics:
◦Standard of care testing to diagnose certain HLA related drug hypersensitivity
reactions when the testing is supported by the clinical literature and is informative for
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Molecular Pathology Procedures (pg. 17 of 17)
Data Source: Local Coverage Determination for
Molecular Pathology Procedures (L35000)
LCD Description: The American Medical Association (AMA) Current Procedural Terminology (CPT) manual states molecular pathology procedures are medical laboratory
procedures involving the analyses of nucleic acid to detect variants in genes that may be indicative of germline (e.g., constitutional disorders) or somatic (e.g., neoplasia)
conditions, or to test for histocompatibility antigens (e.g., HLA). Given the elimination of the stacking procedure codes (83890-83914) and the array based evaluation codes
(88384-88386), molecular pathology codes now include all analytical services performed in the test (e.g., cell lysis, nucleic acid stabilization, extraction, digestion, amplification,
and detection). (Note: molecular pathology procedure techniques may be described in other sections of the Pathology and Laboratory section of CPT. For microbial identification
using molecular pathology techniques CPT codes 87149-87153, 87470-87801, and 87900-87904 apply. For in situ hybridization analyses, CPT codes 88271-88275 and 8836588368 apply.)
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must
be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical record
must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book should be used
as a complete reference.
• Testing assay(s) are Food and Drug Administration (FDA) approved/cleared or if
LDT (lab developed test) or LDT protocol or FDA modified test(s) the laboratory
the direct management of a patient bearing a certain allele(s) associated to fatal
documentation should support assay(s) of analytical validity and clinical utility; AND
skin drug reactions (Stevens-Johnson syndrome and toxic epidermal necrolysis). It
• Results of the testing must directly impact treatment or management of the
is not expected that more than one test would be required in a given beneficiary’s
Medicare beneficiary; AND
lifetime. Possible covered indications:
• For testing panels, including but not limited to, multiple genes or multiple conditions,
◦HLA –B*5701 when testing performed prior to the initiation of an abacavirand in cases where a tiered approach/method is clinically available, testing would be
containing regime in the treatment of HIV Infection.
covered ONLY for the number of genes or test that are reasonable and necessary to
◦HLA-B*1502 when genotyping may be useful for risk stratification when the testing
obtain necessary information for therapeutic decision making; AND
is performed prior to the initiation of carbamazepine therapy in the treatment of
• Individual has not previously received genetic testing for the disease/condition. (In
patients at high risk of having this allele. HLA-B*1502 occurs almost exclusively in
general, diagnostic genetic testing for a disease should be performed once in a
patients with ancestry across broad areas of Asia, including South Asian Indians.
lifetime.) Exceptions include clinical scenarios whereby repeat testing of somatically•Identification of HLA compatible platelets for transfusion when standard typing is
acquired mutations (for example, pre- and post- therapy) may be required to inform
not adequate.
appropriate therapeutic decision-making.
CPT code 81479
ROS proto-oncogene 1, receptor tyrosine kinase, is considered medically
Limitations:
necessary in patients with non-small cell lung cancer when needed to determine if a
• Any procedures required prior to cell lysis (e.g., microdissection [CPT codes 88380
Medicare covered therapy is a reasonable option given the individuals specific
and 88381]) should be reported separately and utilization must be clearly supported
clinical presentation.
based on the application and clinical utility. Such claims may be subject to
Indications:
prepayment medical review.
Molecular pathology procedures (Tier1 and Tier 2) may be eligible for coverage
• HCPCS code G0452 describes the medically necessary interpretation and report of
when ALL of the following criteria are met:
a molecular pathology test, written by a pathologist, which is above and beyond the
• Alternative laboratory or clinical tests to definitively diagnose the disorder/identify
report of standard laboratory results. Non- physician practitioners (e.g., PhD,
the condition are unavailable or results are clearly equivocal; AND
scientists etc.) are not eligible to report this code; only physicians may use/bill this
• Availability of a clinically valid test, based on published peer reviewed medical
code.
literature; AND
• Testing for quality assurance (component of the service is not separately billable
per CMS National Correct Coding Initiative (NCCI).
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-10-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.
Last Updated:
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.
10/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Non-covered Services
CPT Codes: 82172, 83006, 84066, 86152, 86153
Data Source: Local Coverage Determination for
Non-covered Services (L33629)
LCD Description: : Items and services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a
malformed body member are not covered. (CMS Publication 100-02, Chapter 15, Section 20).
This LCD lists specific services which are considered not medically necessary and will be denied. Some of these services were previously included in National Government
Services LCDs which are now retired. The non-coverage provisions have been transferred to this umbrella Non-covered Services LCD.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s
medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM
book should be used as a complete reference.
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY
GROUP 1 PARAGRAPH: FOR PRE-OPERATIVE TESTING (PARTIAL
THROMBOPLASTIN, PROTHROMBIN TIME, SERUM IRON):
GROUP 1 CODES:
Z01.30
ENCOUNTER FOR EXAMINATION OF BLOOD PRESSURE
WITHOUT ABNORMAL FINDINGS
Z01.31
ENCOUNTER FOR EXAMINATION OF BLOOD PRESSURE
WITH ABNORMAL FINDINGS
Z01.810 ENCOUNTER FOR PREPROCEDURAL CARDIOVASCULAR
EXAMINATION
Z01.811 ENCOUNTER FOR PREPROCEDURAL RESPIRATORY
EXAMINATION
Z01.818 ENCOUNTER FOR OTHER PREPROCEDURAL EXAMINATION
Z01.82
ENCOUNTER FOR ALLERGY TESTING
Z01.89
ENCOUNTER FOR OTHER SPECIFIED SPECIAL
EXAMINATIONS
Indications and Limitations:
Pre-operative Testing
The use of diagnostic testing as part of a pre-operative examination, where there is an
absence of signs or symptoms indicating a need for the test, is not covered under the
Medicare benefit. Such studies will be considered not reasonable and medically necessary.
Certain diagnostic tests which are often performed routinely prior to surgical procedures
and do not meet the definition of reasonable and necessary include:
•Electrocardiograms performed pre-operatively, when there are no indications for this test;
•Radiologic examination of the chest performed pre-operatively, when there are no
indications for this test;
•Serum iron studies performed as a pre-operative test when there is no indication of
anemia or recent autologous blood collections prior to surgery.
Claims submitted for these tests performed solely as part of a preoperative examination,
without additional diagnoses indicating medical necessity, will be denied as not reasonable
and necessary
Lipid Profile/Cholesterol Tests
Claims for VLDL ( 83719) and lipoprotein (a) ( 82172) will be denied as not medically
necessary, since NCEP recommendations do not include monitoring of VLDL or
apolipoprotein levels for treatment of elevated cholesterol as risk factors for coronary and
vascular atherosclerosis.
Prostatic acid phosphatase (CPT code 84066) will be denied as not medically necessary
for all diagnoses, including Gaucher's disease and osteoporosis.
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-10-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.
Last Updated:
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.
07/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 1 of 15)
Data Source: Local Coverage Determination
CPT Code: 86003
for RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
L20.0
Besnier's prurigo
L20.81
Atopic neurodermatitis
The following ICD-10 Codes apply only to CPT code 86003:
L20.82
Flexural eczema
L20.84
Intrinsic (allergic) eczema
J30.0
Vasomotor rhinitis
L20.89
Other atopic dermatitis
J30.1
Allergic rhinitis due to pollen
L50.0
Allergic urticaria
J30.2
Other seasonal allergic rhinitis
L50.6
Contact urticaria
J30.5
Allergic rhinitis due to food
L50.8
Other urticaria
J30.81
Allergic rhinitis due to animal (cat) (dog) hair and dander
L50.9
Urticaria, unspecified
J30.89
Other allergic rhinitis
R06.2
Wheezing
J30.9
Allergic rhinitis, unspecified
T36.0X5A Adverse effect of penicillins, initial encounter
J45.20
Mild intermittent asthma, uncomplicated
T36.0X5D Adverse effect of penicillins, subsequent encounter
J45.21
Mild intermittent asthma with (acute) exacerbation
T36.0X5S Adverse effect of penicillins, sequela
J45.22
Mild intermittent asthma with status asthmaticus
T36.1X5A Adverse effect of cephalosporins and other beta-lactam antibiotics, initial
J45.30
Mild persistent asthma, uncomplicated
encounter
J45.31
Mild persistent asthma with (acute) exacerbation
T36.1X5D Adverse effect of cephalosporins and other beta-lactam antibiotics,
J45.32
Mild persistent asthma with status asthmaticus
subsequent encounter
J45.40
Moderate persistent asthma, uncomplicated
T36.1X5S Adverse effect of cephalosporins and other beta-lactam antibiotics,
J45.41
Moderate persistent asthma with (acute) exacerbation
sequela
J45.42
Moderate persistent asthma with status asthmaticus
T36.2X5A
Adverse effect of chloramphenicol group, initial encounter
J45.50
Severe persistent asthma, uncomplicated
T36.2X5D Adverse effect of chloramphenicol group, subsequent encounter
J45.51
Severe persistent asthma with (acute) exacerbation
T36.2X5S Adverse effect of chloramphenicol group, sequela
J45.52
Severe persistent asthma with status asthmaticus
T36.3X5A Adverse effect of macrolides, initial encounter
J45.901 Unspecified asthma with (acute) exacerbation
T36.3X5D Adverse effect of macrolides, subsequent encounter
J45.902 Unspecified asthma with status asthmaticus
T36.3X5S Adverse effect of macrolides, sequela
J45.909 Unspecified asthma, uncomplicated
T36.4X5A Adverse effect of tetracyclines, initial encounter
J45.991 Cough variant asthma
T36.4X5D Adverse effect of tetracyclines, subsequent encounter
J45.998 Other asthma
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 2 of 15)
Data Source: Local Coverage Determination for
CPT Code: 86003
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T37.2X5D Adverse effect of antimalarials and drugs acting on other blood protozoa,
subsequent encounter
T36.4X5S Adverse effect of tetracyclines, sequela
T37.2X5S Adverse effect of antimalarials and drugs acting on other blood protozoa,
T36.5X5A Adverse effect of aminoglycosides, initial encounter
sequela
T36.5X5D Adverse effect of aminoglycosides, subsequent encounter
T37.3X5A Adverse effect of other antiprotozoal drugs, initial encounter
T36.5X5S Adverse effect of aminoglycosides, sequela
T37.3X5D Adverse effect of other antiprotozoal drugs, subsequent encounter
T36.6X5A Adverse effect of rifampicins, initial encounter
T37.3X5S Adverse effect of other antiprotozoal drugs, sequela
T36.6X5D Adverse effect of rifampicins, subsequent encounter
T37.4X5A Adverse effect of anthelminthics, initial encounter
T36.6X5S Adverse effect of rifampicins, sequela
T37.4X5D Adverse effect of anthelminthics, subsequent encounter
T36.7X5A Adverse effect of antifungal antibiotics, systemically used, initial
T37.4X5S Adverse effect of anthelminthics, sequela
encounter
T37.5X5A Adverse effect of antiviral drugs, initial encounter
T36.7X5D Adverse effect of antifungal antibiotics, systemically used, subsequent
T37.5X5D Adverse effect of antiviral drugs, subsequent encounter
encounter
T37.5X5S Adverse effect of antiviral drugs, sequela
T36.7X5S Adverse effect of antifungal antibiotics, systemically used, sequela
T37.8X5A Adverse effect of other specified systemic anti-infectives and
T36.8X5A Adverse effect of other systemic antibiotics, initial encounter
antiparasitics, initial encounter
T36.8X5D Adverse effect of other systemic antibiotics, subsequent encounter
T37.8X5D Adverse effect of other specified systemic anti-infectives and
T36.8X5S Adverse effect of other systemic antibiotics, sequela
antiparasitics, subsequent encounter
T36.95XA Adverse effect of unspecified systemic antibiotic, initial encounter
T37.8X5S Adverse effect of other specified systemic anti-infectives and
T36.95XD Adverse effect of unspecified systemic antibiotic, subsequent encounter
antiparasitics, sequela
T36.95XS Adverse effect of unspecified systemic antibiotic, sequela
T37.95XA
Adverse
effect of unspecified systemic anti-infective and antiparasitic,
T37.0X5A Adverse effect of sulfonamides, initial encounter
initial encounter
T37.0X5D Adverse effect of sulfonamides, subsequent encounter
T37.95XD Adverse effect of unspecified systemic anti-infective and antiparasitic,
T37.0X5S Adverse effect of sulfonamides, sequela
subsequent encounter
T37.1X5A Adverse effect of antimycobacterial drugs, initial encounter
T37.95XS
Adverse
effect of unspecified systemic anti-infective and antiparasitic,
T37.1X5D Adverse effect of antimycobacterial drugs, subsequent encounter
sequela
T37.1X5S Adverse effect of antimycobacterial drugs, sequela
T38.0X5A Adverse effect of glucocorticoids and synthetic analogues, initial
T37.2X5A Adverse effect of antimalarials and drugs acting on other blood
encounter
protozoa, initial encounter
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 3 of 15)
Data Source: Local Coverage Determination for
CPT Code: 86003
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T38.7X5S Adverse effect of androgens and anabolic congeners, sequela
T38.805A Adverse effect of unspecified hormones and synthetic substitutes, initial
T38.0X5D Adverse effect of glucocorticoids and synthetic analogues, subsequent
encounter
encounter
T38.805D
Adverse
effect of unspecified hormones and synthetic substitutes,
T38.0X5S Adverse effect of glucocorticoids and synthetic analogues, sequela
subsequent encounter
T38.1X5A Adverse effect of thyroid hormones and substitutes, initial encounter
T38.805S Adverse effect of unspecified hormones and synthetic substitutes, sequela
T38.1X5D Adverse effect of thyroid hormones and substitutes, subsequent
T38.815A Adverse effect of anterior pituitary [adenohypophyseal] hormones, initial
encounter
encounter
T38.1X5S Adverse effect of thyroid hormones and substitutes, sequela
T38.815D Adverse effect of anterior pituitary [adenohypophyseal] hormones,
T38.2X5A Adverse effect of antithyroid drugs, initial encounter
subsequent encounter
T38.2X5D Adverse effect of antithyroid drugs, subsequent encounter
T38.815S Adverse effect of anterior pituitary [adenohypophyseal] hormones, sequela
T38.2X5S Adverse effect of antithyroid drugs, sequela
T38.895A Adverse effect of other hormones and synthetic substitutes, initial
T38.4X5A Adverse effect of oral contraceptives, initial encounter
encounter
T38.4X5D Adverse effect of oral contraceptives, subsequent encounter
T38.895D Adverse effect of other hormones and synthetic substitutes, subsequent
T38.4X5S Adverse effect of oral contraceptives, sequela
encounter
T38.5X5A Adverse effect of other estrogens and progestogens, initial encounter
T38.895S Adverse effect of other hormones and synthetic substitutes, sequela
T38.5X5D Adverse effect of other estrogens and progestogens, subsequent
T38.905A Adverse effect of unspecified hormone antagonists, initial encounter
encounter
T38.905D Adverse effect of unspecified hormone antagonists, subsequent encounter
T38.5X5S Adverse effect of other estrogens and progestogens, sequela
T38.905S Adverse effect of unspecified hormone antagonists, sequela
T38.6X5A Adverse effect of antigonadotrophins, antiestrogens, antiandrogens,
T38.995A Adverse effect of other hormone antagonists, initial encounter
not elsewhere classified, initial encounter
T38.995D Adverse effect of other hormone antagonists, subsequent encounter
T38.6X5D Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not
T38.995S Adverse effect of other hormone antagonists, sequela
elsewhere classified, subsequent encounter
T39.015A Adverse effect of aspirin, initial encounter
T38.6X5S Adverse effect of antigonadotrophins, antiestrogens, antiandrogens, not
T39.015D Adverse effect of aspirin, subsequent encounter
classified, sequela
T39.015S Adverse effect of aspirin, sequela
T38.7X5A Adverse effect of androgens and anabolic congeners, initial encounter
T39.095A Adverse effect of salicylates, initial encounter
T38.7X5D Adverse effect of androgens and anabolic congeners, subsequent
T39.095D Adverse effect of salicylates, subsequent encounter
encounter
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 4 of 15)
Data Source: Local Coverage Determination for
CPT Code: 86003
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T39.95XA Adverse effect of unspecified nonopioid analgesic, antipyretic and
antirheumatic, initial encounter
T39.095S Adverse effect of salicylates, sequela
T39.95XD Adverse effect of unspecified nonopioid analgesic, antipyretic and
T39.1X5A Adverse effect of 4-Aminophenol derivatives, initial encounter
antirheumatic, subsequent encounter
T39.1X5D Adverse effect of 4-Aminophenol derivatives, subsequent encounter
T39.95XS Adverse effect of unspecified nonopioid analgesic, antipyretic and
T39.1X5S Adverse effect of 4-Aminophenol derivatives, sequela
antirheumatic, sequela
T39.2X5A Adverse effect of pyrazolone derivatives, initial encounter
T40.0X5A
Adverse effect of opium, initial encounter
T39.2X5D Adverse effect of pyrazolone derivatives, subsequent encounter
T40.0X5D Adverse effect of opium, subsequent encounter
T39.2X5S Adverse effect of pyrazolone derivatives, sequela
T40.0X5S Adverse effect of opium, sequela
T39.315A Adverse effect of propionic acid derivatives, initial encounter
T40.2X5A Adverse effect of other opioids, initial encounter
T39.315D Adverse effect of propionic acid derivatives, subsequent encounter
T40.2X5D Adverse effect of other opioids, subsequent encounter
T39.315S Adverse effect of propionic acid derivatives, sequela
T39.395A Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID], initial T40.2X5S Adverse effect of other opioids, sequela
T40.3X5A Adverse effect of methadone, initial encounter
encounter
T40.3X5D Adverse effect of methadone, subsequent encounter
T39.395D Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID],
T40.3X5S Adverse effect of methadone, sequela
subsequent encounter
T40.4X5A Adverse effect of other synthetic narcotics, initial encounter
T39.395S Adverse effect of other nonsteroidal anti-inflammatory drugs [NSAID],
T40.4X5D Adverse effect of other synthetic narcotics, subsequent encounter
sequela
T39.4X5A Adverse effect of antirheumatics, not elsewhere classified, initial encounter T40.4X5S Adverse effect of other synthetic narcotics, sequela
T40.5X5A Adverse effect of cocaine, initial encounter
T39.4X5D Adverse effect of antirheumatics, not elsewhere classified, subsequent
T40.5X5D Adverse effect of cocaine, subsequent encounter
encounter
T40.5X5S Adverse effect of cocaine, sequela
T39.4X5S Adverse effect of antirheumatics, not elsewhere classified, sequela
T40.605A Adverse effect of unspecified narcotics, initial encounter
T39.8X5A Adverse effect of other nonopioid analgesics and antipyretics, not
T40.605D Adverse effect of unspecified narcotics, subsequent encounter
elsewhere classified, initial encounter
T40.605S Adverse effect of unspecified narcotics, sequela
T39.8X5D Adverse effect of other nonopioid analgesics and antipyretics, not
T40.695A Adverse effect of other narcotics, initial encounter
elsewhere classified, subsequent encounter
T40.695D Adverse effect of other narcotics, subsequent encounter
T39.8X5S Adverse effect of other nonopioid analgesics and antipyretics, not
T40.695S Adverse effect of other narcotics, sequela
elsewhere classified, sequela
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 5 of 15)
Data Source: Local Coverage Determination for
CPT Code: 86003
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T41.5X5D Adverse effect of therapeutic gases, subsequent encounter
T41.5X5S Adverse effect of therapeutic gases, sequela
T40.7X5A Adverse effect of cannabis (derivatives), initial encounter
T42.0X5A Adverse effect of hydantoin derivatives, initial encounter
T40.7X5D Adverse effect of cannabis (derivatives), subsequent encounter
T42.0X5D Adverse effect of hydantoin derivatives, subsequent encounter
T40.7X5S Adverse effect of cannabis (derivatives), sequela
T42.0X5S Adverse effect of hydantoin derivatives, sequela
T40.905A Adverse effect of unspecified psychodysleptics [hallucinogens], initial
T42.1X5A Adverse effect of iminostilbenes, initial encounter
encounter
T42.1X5D Adverse effect of iminostilbenes, subsequent encounter
T40.905D Adverse effect of unspecified psychodysleptics [hallucinogens],
T42.1X5S Adverse effect of iminostilbenes, sequela
subsequent encounter
T42.2X5A Adverse effect of succinimides and oxazolidinediones, initial encounter
T40.905S Adverse effect of unspecified psychodysleptics [hallucinogens], sequela
T42.2X5D Adverse effect of succinimides and oxazolidinediones, subsequent
T40.995A Adverse effect of other psychodysleptics [hallucinogens], initial
encounter
encounter
T42.2X5S Adverse effect of succinimides and oxazolidinediones, sequela
T40.995D Adverse effect of other psychodysleptics [hallucinogens], subsequent
T42.3X5A Adverse effect of barbiturates, initial encounter
encounter
T42.3X5D Adverse effect of barbiturates, subsequent encounter
T40.995S Adverse effect of other psychodysleptics [hallucinogens], sequela
T42.3X5S Adverse effect of barbiturates, sequela
T41.0X5A Adverse effect of inhaled anesthetics, initial encounter
T42.4X5A Adverse effect of benzodiazepines, initial encounter
T41.0X5D Adverse effect of inhaled anesthetics, subsequent encounter
T42.4X5D Adverse effect of benzodiazepines, subsequent encounter
T41.0X5S Adverse effect of inhaled anesthetics, sequela
T42.4X5S Adverse effect of benzodiazepines, sequela
T41.1X5A Adverse effect of intravenous anesthetics, initial encounter
T42.5X5A Adverse effect of mixed antiepileptics, initial encounter
T41.1X5D Adverse effect of intravenous anesthetics, subsequent encounter
T42.5X5D Adverse effect of mixed antiepileptics, subsequent encounter
T41.1X5S Adverse effect of intravenous anesthetics, sequela
T42.5X5S Adverse effect of mixed antiepileptics, sequela
T41.295A Adverse effect of other general anesthetics, initial encounter
T42.6X5A Adverse effect of other antiepileptic and sedative-hypnotic drugs, initial
T41.295D Adverse effect of other general anesthetics, subsequent encounter
encounter
T41.295S Adverse effect of other general anesthetics, sequela
T42.6X5D
Adverse effect of other antiepileptic and sedative-hypnotic drugs,
T41.3X5A Adverse effect of local anesthetics, initial encounter
subsequent encounter
T41.3X5D Adverse effect of local anesthetics, subsequent encounter
T42.6X5S Adverse effect of other antiepileptic and sedative-hypnotic drugs,
T41.3X5S Adverse effect of local anesthetics, sequela
sequela
T41.5X5A Adverse effect of therapeutic gases, initial encounter
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 6 of 15)
Data Source: Local Coverage Determination for
CPT Code: 86003
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T43.205D Adverse effect of unspecified antidepressants, subsequent encounter
T43.205S Adverse effect of unspecified antidepressants, sequela
T42.75XA Adverse effect of unspecified antiepileptic and sedative-hypnotic drugs,
T43.215A Adverse effect of selective serotonin and norepinephrine reuptake
initial encounter
inhibitors, initial encounter
T42.75XD Adverse effect of unspecified antiepileptic and sedative-hypnotic drugs,
T43.215D Adverse effect of selective serotonin and norepinephrine reuptake
subsequent encounter
inhibitors, subsequent encounter
T42.75XS Adverse effect of unspecified antiepileptic and sedative-hypnotic drugs,
T43.215S
Adverse
effect of selective serotonin and norepinephrine reuptake
sequela
inhibitors, sequela
T42.8X5A Adverse effect of antiparkinsonism drugs and other central muscleT43.225A Adverse effect of selective serotonin reuptake inhibitors, initial encounter
tone depressants, initial encounter
T43.225D Adverse effect of selective serotonin reuptake inhibitors, subsequent
T42.8X5D Adverse effect of antiparkinsonism drugs and other central muscleencounter
tone depressants, subsequent encounter
T43.225S Adverse effect of selective serotonin reuptake inhibitors, sequela
T42.8X5S Adverse effect of antiparkinsonism drugs and other central muscleT43.295A Adverse effect of other antidepressants, initial encounter
tone depressants, sequela
T43.295D Adverse effect of other antidepressants, subsequent encounter
T43.015A Adverse effect of tricyclic antidepressants, initial encounter
T43.295S Adverse effect of other antidepressants, sequela
T43.015D Adverse effect of tricyclic antidepressants, subsequent encounter
T43.3X5A Adverse effect of phenothiazine antipsychotics and neuroleptics, initial
T43.015S Adverse effect of tricyclic antidepressants, sequela
encounter
T43.025A Adverse effect of tetracyclic antidepressants, initial encounter
T43.3X5S Adverse effect of phenothiazine antipsychotics and neuroleptics, sequela
T43.025D Adverse effect of tetracyclic antidepressants, subsequent encounter
T43.3X5D Adverse effect of phenothiazine antipsychotics and neuroleptics,
T43.025S Adverse effect of tetracyclic antidepressants, sequela
subsequent encounter
T43.1X5A Adverse effect of monoamine-oxidase-inhibitor antidepressants, initial
T43.4X5A Adverse effect of butyrophenone and thiothixene neuroleptics, initial
encounter
encounter
T43.1X5D Adverse effect of monoamine-oxidase-inhibitor antidepressants,
T43.4X5D Adverse effect of butyrophenone and thiothixene neuroleptics,
subsequent encounter
subsequent encounter
T43.1X5S Adverse effect of monoamine-oxidase-inhibitor antidepressants,
T43.4X5S Adverse effect of butyrophenone and thiothixene neuroleptics, sequela
sequela
T43.505A Adverse effect of unspecified antipsychotics and neuroleptics, initial
T43.205A Adverse effect of unspecified antidepressants, initial encounter
encounter
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 7 of 15)
Data Source: Local Coverage Determination for
CPT Code: 86003
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T43.95XA Adverse effect of unspecified psychotropic drug, initial encounter
T43.95XD Adverse effect of unspecified psychotropic drug, subsequent encounter
T43.505D Adverse effect of unspecified antipsychotics and neuroleptics,
T43.95XS Adverse effect of unspecified psychotropic drug, sequela
subsequent encounter
T44.0X5A Adverse effect of anticholinesterase agents, initial encounter
T43.505S Adverse effect of unspecified antipsychotics and neuroleptics, sequela
T44.0X5D Adverse effect of anticholinesterase agents, subsequent encounter
T43.595A Adverse effect of other antipsychotics and neuroleptics, initial encounter
T44.0X5S Adverse effect of anticholinesterase agents, sequela
T43.595D Adverse effect of other antipsychotics and neuroleptics, subsequent
T44.1X5A Adverse effect of other parasympathomimetics [cholinergics], initial
encounter
encounter
T43.595S Adverse effect of other antipsychotics and neuroleptics, sequela
T44.1X5D Adverse effect of other parasympathomimetics [cholinergics], subsequent
T43.605A Adverse effect of unspecified psychostimulants, initial encounter
encounter
T43.605D Adverse effect of unspecified psychostimulants, subsequent encounter
T44.1X5S Adverse effect of other parasympathomimetics [cholinergics], sequela
T43.605S Adverse effect of unspecified psychostimulants, sequela
T44.2X5A Adverse effect of ganglionic blocking drugs, initial encounter
T43.615A Adverse effect of caffeine, initial encounter
T44.2X5D Adverse effect of ganglionic blocking drugs, subsequent encounter
T43.615D Adverse effect of caffeine, subsequent encounter
T44.2X5S Adverse effect of ganglionic blocking drugs, sequela
T43.615S Adverse effect of caffeine, sequela
T44.3X5A Adverse effect of other parasympatholytics [anticholinergics and
T43.625A Adverse effect of amphetamines, initial encounter
antimuscarinics] and spasmolytics, initial encounter
T43.625D Adverse effect of amphetamines, subsequent encounter
T44.3X5D
Adverse effect of other parasympatholytics [anticholinergics and
T43.625S Adverse effect of amphetamines, sequela
antimuscarinics] and spasmolytics, subsequent encounter
T43.635A Adverse effect of methylphenidate, initial encounter
T44.3X5S Adverse effect of other parasympatholytics [anticholinergics and
T43.635D Adverse effect of methylphenidate, subsequent encounter
antimuscarinics] and spasmolytics, sequela
T43.635S Adverse effect of methylphenidate, sequela
T44.4X5A Adverse effect of predominantly alpha-adrenoreceptor agonists, initial
T43.695A Adverse effect of other psychostimulants, initial encounter
encounter
T43.695D Adverse effect of other psychostimulants, subsequent encounter
T44.4X5D Adverse effect of predominantly alpha-adrenoreceptor agonists,
T43.695S Adverse effect of other psychostimulants, sequela
subsequent encounter
T43.8X5A Adverse effect of other psychotropic drugs, initial encounter
T44.4X5S Adverse effect of predominantly alpha-adrenoreceptor agonists, sequela
T43.8X5D Adverse effect of other psychotropic drugs, subsequent encounter
T44.5X5A Adverse effect of predominantly beta-adrenoreceptor agonists, initial
T43.8X5S Adverse effect of other psychotropic drugs, sequela
encounter
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 8 of 15)
Data Source: Local Coverage Determination for
CPT Code: 86003
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T44.995S Adverse effect of other drug primarily affecting the autonomic nervous
T44.5X5D Adverse effect of predominantly beta-adrenoreceptor agonists,
system, sequela
subsequent encounter
T45.0X5A Adverse effect of antiallergic and antiemetic drugs, initial encounter
T44.5X5S Adverse effect of predominantly beta-adrenoreceptor agonists, sequela
T45.0X5D Adverse effect of antiallergic and antiemetic drugs, subsequent encounter
T44.6X5A Adverse effect of alpha-adrenoreceptor antagonists, initial encounter
T45.0X5S Adverse effect of antiallergic and antiemetic drugs, sequela
T44.6X5D Adverse effect of alpha-adrenoreceptor antagonists, subsequent
T45.1X5A Adverse effect of antineoplastic and immunosuppressive drugs, initial
encounter
encounter
T44.6X5S Adverse effect of alpha-adrenoreceptor antagonists, sequela
T45.1X5D Adverse effect of antineoplastic and immunosuppressive drugs,
T44.7X5A Adverse effect of beta-adrenoreceptor antagonists, initial encounter
subsequent encounter
T44.7X5D Adverse effect of beta-adrenoreceptor antagonists, subsequent
T45.1X5S Adverse effect of antineoplastic and immunosuppressive drugs, sequela
encounter
T45.2X5A Adverse effect of vitamins, initial encounter
T44.7X5S Adverse effect of beta-adrenoreceptor antagonists, sequela
T45.2X5D Adverse effect of vitamins, subsequent encounter
T44.8X5A Adverse effect of centrally-acting and adrenergic-neuron-blocking
T45.2X5S Adverse effect of vitamins, sequela
agents, initial encounter
T45.3X5A Adverse effect of enzymes, initial encounter
T44.8X5D Adverse effect of centrally-acting and adrenergic-neuron-blocking
T45.3X5D Adverse effect of enzymes, subsequent encounter
agents, subsequent encounter
T45.3X5S Adverse effect of enzymes, sequela
44.8X5S Adverse effect of centrally-acting and adrenergic-neuron-blocking agents, T45.4X5A Adverse effect of iron and its compounds, initial encounter
sequela
T45.4X5D Adverse effect of iron and its compounds, subsequent encounter
T44.905A Adverse effect of unspecified drugs primarily affecting the autonomic
T45.4X5S Adverse effect of iron and its compounds, sequela
nervous system, initial encounter
T45.515A Adverse effect of anticoagulants, initial encounter
T44.905D Adverse effect of unspecified drugs primarily affecting the autonomic
T45.515D Adverse effect of anticoagulants, subsequent encounter
nervous system, subsequent encounter
T45.515S Adverse effect of anticoagulants, sequela
T44.905S Adverse effect of unspecified drugs primarily affecting the autonomic
T45.525A Adverse effect of antithrombotic drugs, initial encounter
nervous system, sequela
T45.525D Adverse effect of antithrombotic drugs, subsequent encounter
T44.995A Adverse effect of other drug primarily affecting the autonomic nervous
T45.525S Adverse effect of antithrombotic drugs, sequela
system, initial encounter
T45.605A Adverse effect of unspecified fibrinolysis-affecting drugs, initial encounter
TT44.995D Adverse effect of other drug primarily affecting the autonomic nervous
T45.605D Adverse effect of unspecified fibrinolysis-affecting drugs, subsequent
system, subsequent encounter
encounter
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 9 of 15)
CPT Code: 86003
Data Source: Local Coverage Determination for
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T45.95XS Adverse effect of unspecified primarily systemic and hematological agent,
sequela
T45.605S Adverse effect of unspecified fibrinolysis-affecting drugs, sequela
T46.0X5A Adverse effect of cardiac-stimulant glycosides and drugs of similar action,
T45.615A Adverse effect of thrombolytic drugs, initial encounter
initial encounter
T45.615D Adverse effect of thrombolytic drugs, subsequent encounter
T46.0X5D Adverse effect of cardiac-stimulant glycosides and drugs of similar action,
T45.615S Adverse effect of thrombolytic drugs, sequela
subsequent encounter
T45.625A Adverse effect of hemostatic drug, initial encounter
T46.0X5S Adverse effect of cardiac-stimulant glycosides and drugs of similar action,
T45.625D Adverse effect of hemostatic drug, subsequent encounter
sequela
T45.625S Adverse effect of hemostatic drug, sequela
T46.1X5A Adverse effect of calcium-channel blockers, initial encounter
T45.695A Adverse effect of other fibrinolysis-affecting drugs, initial encounter
T45.695D Adverse effect of other fibrinolysis-affecting drugs, subsequent encounter T46.1X5D Adverse effect of calcium-channel blockers, subsequent encounter
T46.1X5S Adverse effect of calcium-channel blockers, sequela
T45.695S Adverse effect of other fibrinolysis-affecting drugs, sequela
T46.2X5A Adverse effect of other antidysrhythmic drugs, initial encounter
T45.7X5A Adverse effect of anticoagulant antagonists, vitamin K and other
T46.2X5D Adverse effect of other antidysrhythmic drugs, subsequent encounter
coagulants, initial encounter
T46.2X5S Adverse effect of other antidysrhythmic drugs, sequela
T45.7X5D Adverse effect of anticoagulant antagonists, vitamin K and other
T46.3X5A Adverse effect of coronary vasodilators, initial encounter
coagulants, subsequent encounter
T46.3X5D Adverse effect of coronary vasodilators, subsequent encounter
T45.7X5S Adverse effect of anticoagulant antagonists, vitamin K and other
T46.3X5S Adverse effect of coronary vasodilators, sequela
coagulants, sequela
T46.4X5A Adverse effect of angiotensin-converting-enzyme inhibitors, initial
T45.8X5A Adverse effect of other primarily systemic and hematological agents,
encounter
initial encounter
T46.4X5D Adverse effect of angiotensin-converting-enzyme inhibitors, subsequent
T45.8X5D Adverse effect of other primarily systemic and hematological agents,
encounter
subsequent encounter
T46.4X5S Adverse effect of angiotensin-converting-enzyme inhibitors, sequela
T45.8X5S Adverse effect of other primarily systemic and hematological agents,
T46.5X5A Adverse effect of other antihypertensive drugs, initial encounter
sequela
T46.5X5D Adverse effect of other antihypertensive drugs, subsequent encounter
T45.95XA Adverse effect of unspecified primarily systemic and hematological
T46.5X5S Adverse effect of other antihypertensive drugs, sequela
agent, initial encounter
T46.6X5A Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs, initial
T45.95XD Adverse effect of unspecified primarily systemic and hematological
encounter
agent, subsequent encounter
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 10 of 15)
CPT Code: 86003
Data Source: Local Coverage Determination for
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T47.0X5A Adverse effect of histamine H2-receptor blockers, initial encounter
T46.6X5D Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs,
T47.0X5D Adverse effect of histamine H2-receptor blockers, subsequent encounter
subsequent encounter
T47.0X5S Adverse effect of histamine H2-receptor blockers, sequela
T46.6X5S Adverse effect of antihyperlipidemic and antiarteriosclerotic drugs,
T47.1X5A Adverse effect of other antacids and anti-gastric-secretion drugs, initial
sequela
encounter
T46.7X5A Adverse effect of peripheral vasodilators, initial encounter
T47.1X5D Adverse effect of other antacids and anti-gastric-secretion drugs,
T46.7X5D Adverse effect of peripheral vasodilators, subsequent encounter
subsequent encounter
T46.7X5S Adverse effect of peripheral vasodilators, sequela
T47.1X5S Adverse effect of other antacids and anti-gastric-secretion drugs, sequela
T46.8X5A Adverse effect of antivaricose drugs, including sclerosing agents, initial
T47.2X5A Adverse effect of stimulant laxatives, initial encounter
encounter
T47.2X5D Adverse effect of stimulant laxatives, subsequent encounter
T46.8X5D Adverse effect of antivaricose drugs, including sclerosing agents,
T47.2X5S Adverse effect of stimulant laxatives, sequela
subsequent encounter
T47.3X5A Adverse effect of saline and osmotic laxatives, initial encounter
T46.8X5S Adverse effect of antivaricose drugs, including sclerosing agents,
T47.3X5D Adverse effect of saline and osmotic laxatives, subsequent encounter
sequela
T47.3X5S Adverse effect of saline and osmotic laxatives, sequela
T46.905A Adverse effect of unspecified agents primarily affecting the
T47.4X5A Adverse effect of other laxatives, initial encounter
cardiovascular system, initial encounter
T47.4X5D Adverse effect of other laxatives, subsequent encounter
T46.905D Adverse effect of unspecified agents primarily affecting the
T47.4X5S Adverse effect of other laxatives, sequela
cardiovascular system, subsequent encounter
T47.5X5A Adverse effect of digestants, initial encounter
T46.905S Adverse effect of unspecified agents primarily affecting the
T47.5X5D Adverse effect of digestants, subsequent encounter
cardiovascular system, sequela
T47.5X5S Adverse effect of digestants, sequela
T46.995A Adverse effect of other agents primarily affecting the cardiovascular
T47.6X5A Adverse effect of antidiarrheal drugs, initial encounter
system, initial encounter
T47.6X5D Adverse effect of antidiarrheal drugs, subsequent encounter
T46.995D Adverse effect of other agents primarily affecting the cardiovascular
T47.6X5S Adverse effect of antidiarrheal drugs, sequela
system, subsequent encounter
T47.7X5A Adverse effect of emetics, initial encounter
T46.995S Adverse effect of other agents primarily affecting the cardiovascular
T47.7X5D Adverse effect of emetics, subsequent encounter
system, sequela
T47.7X5S Adverse effect of emetics, sequela
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 11 of 15)
CPT Code: 86003
Data Source: Local Coverage Determination for
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T48.205S Adverse effect of unspecified drugs acting on muscles, sequela
T47.8X5A Adverse effect of other agents primarily affecting gastrointestinal
T48.295A Adverse effect of other drugs acting on muscles, initial encounter
system, initial encounter
T48.295D Adverse effect of other drugs acting on muscles, subsequent encounter
T47.8X5D Adverse effect of other agents primarily affecting gastrointestinal
T48.295S Adverse effect of other drugs acting on muscles, sequela
system, subsequent encounter
T48.3X5A Adverse effect of antitussives, initial encounter
T47.8X5S Adverse effect of other agents primarily affecting gastrointestinal
T48.3X5D Adverse effect of antitussives, subsequent encounter
system, sequela
T48.3X5S Adverse effect of antitussives, sequela
T47.95XA Adverse effect of unspecified agents primarily affecting the
T48.4X5A Adverse effect of expectorants, initial encounter
gastrointestinal system, initial encounter
T48.4X5D Adverse effect of expectorants, subsequent encounter
T47.95XD Adverse effect of unspecified agents primarily affecting the
T48.4X5S Adverse effect of expectorants, sequela
gastrointestinal system, subsequent encounter
T48.5X5A Adverse effect of other anti-common-cold drugs, initial encounter
T47.95XS Adverse effect of unspecified agents primarily affecting the
T48.5X5D Adverse effect of other anti-common-cold drugs, subsequent encounter
gastrointestinal system, sequela
T48.5X5S Adverse effect of other anti-common-cold drugs, sequela
T48.0X5A Adverse effect of oxytocic drugs, initial encounter
T48.6X5A Adverse effect of antiasthmatics, initial encounter
T48.0X5D Adverse effect of oxytocic drugs, subsequent encounter
T48.6X5D Adverse effect of antiasthmatics, subsequent encounter
T48.0X5S Adverse effect of oxytocic drugs, sequela
T48.6X5S Adverse effect of antiasthmatics, sequela
T48.1X5A Adverse effect of skeletal muscle relaxants [neuromuscular blocking
T48.905A Adverse effect of unspecified agents primarily acting on the
agents], initial encounter
respiratory system, initial encounter
T48.1X5D Adverse effect of skeletal muscle relaxants [neuromuscular blocking
T48.905D Adverse effect of unspecified agents primarily acting on the
agents], subsequent encounter
respiratory system, subsequent encounter
T48.1X5S Adverse effect of skeletal muscle relaxants [neuromuscular blocking
T48.905S Adverse effect of unspecified agents primarily acting on the
agents], sequela
respiratory system, sequela
T48.205A Adverse effect of unspecified drugs acting on muscles, initial
T48.995A Adverse effect of other agents primarily acting on the respiratory
encounter
system, initial encounter
T48.205D Adverse effect of unspecified drugs acting on muscles, subsequent
T48.995D Adverse effect of other agents primarily acting on the respiratory
encounter
system, subsequent encounter
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 12 of 15)
CPT Code: 86003
Data Source: Local Coverage Determination for
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T49.4X5S Adverse effect of keratolytics, keratoplastics, and other hair treatment drugs
and preparations, sequela
T48.995S Adverse effect of other agents primarily acting on the respiratory
T49.5X5A Adverse effect of ophthalmological drugs and preparations, initial encounter
system, sequela
T49.5X5D Adverse effect of ophthalmological drugs and preparations, subsequent
T49.0X5A Adverse effect of local antifungal, anti-infective and antiencounter
inflammatory drugs, initial encounter
T49.5X5S Adverse effect of ophthalmological drugs and preparations, sequela
T49.0X5D Adverse effect of local antifungal, anti-infective and anti-inflammatory
T49.6X5A Adverse effect of otorhinolaryngological drugs and preparations, initial
drugs, subsequent encounter
encounter
T49.0X5S Adverse effect of local antifungal, anti-infective and anti-inflammatory
T49.6X5D Adverse effect of otorhinolaryngological drugs and preparations,
drugs, sequela
subsequent encounter
T49.1X5A Adverse effect of antipruritics, initial encounter
T49.6X5S Adverse effect of otorhinolaryngological drugs and preparations, sequela
T49.1X5D Adverse effect of antipruritics, subsequent encounter
T49.8X5A Adverse effect of other topical agents, initial encounter
T49.1X5S Adverse effect of antipruritics, sequela
T49.8X5D Adverse effect of other topical agents, subsequent encounter
T49.2X5A Adverse effect of local astringents and local detergents, initial
T49.8X5S Adverse effect of other topical agents, sequela
encounter
T49.95XA Adverse effect of unspecified topical agent, initial encounter
T49.2X5D Adverse effect of local astringents and local detergents, subsequent
T49.95XD Adverse effect of unspecified topical agent, subsequent encounter
encounter
T49.95XS Adverse effect of unspecified topical agent, sequela
T49.2X5S Adverse effect of local astringents and local detergents, sequela
T50.0X5A Adverse effect of mineralocorticoids and their antagonists, initial
T49.3X5A Adverse effect of emollients, demulcents and protectants, initial
encounter
encounter
T50.0X5D
Adverse effect of mineralocorticoids and their antagonists,
T49.3X5D Adverse effect of emollients, demulcents and protectants, subsequent
subsequent encounter
encounter
T50.0X5S Adverse effect of mineralocorticoids and their antagonists, sequela
T49.3X5S Adverse effect of emollients, demulcents and protectants, sequela
T50.1X5A Adverse effect of loop [high-ceiling] diuretics, initial encounter
T49.4X5A Adverse effect of keratolytics, keratoplastics, and other hair treatment
T50.1X5D Adverse effect of loop [high-ceiling] diuretics, subsequent encounter
drugs and preparations, initial encounter
T50.1X5S Adverse effect of loop [high-ceiling] diuretics, sequela
T49.4X5D Adverse effect of keratolytics, keratoplastics, and other hair treatment
T50.2X5A Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and
drugs and preparations, subsequent encounter
other diuretics, initial encounter
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 13 of 15)
CPT Code: 86003
Data Source: Local Coverage Determination for
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T50.8X5D Adverse effect of diagnostic agents, subsequent encounter
T50.2X5D Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and
T50.8X5S Adverse effect of diagnostic agents, sequela
other diuretics, subsequent encounter
T50.A15A Adverse effect of pertussis vaccine, including combinations with a
T50.2X5S Adverse effect of carbonic-anhydrase inhibitors, benzothiadiazides and
pertussis component, initial encounter
other diuretics, sequela
T50.A15D Adverse effect of pertussis vaccine, including combinations with a
T50.3X5A Adverse effect of electrolytic, caloric and water-balance agents, initial
pertussis component, subsequent encounter
encounter
T50.A15S Adverse effect of pertussis vaccine, including combinations with a
T50.3X5D Adverse effect of electrolytic, caloric and water-balance agents,
pertussis component, sequela
subsequent encounter
T50.A25A Adverse effect of mixed bacterial vaccines without a pertussis component,
T50.3X5S Adverse effect of electrolytic, caloric and water-balance agents, sequela
initial encounter
T50.4X5A Adverse effect of drugs affecting uric acid metabolism, initial encounter
T50.A25D Adverse effect of mixed bacterial vaccines without a pertussis component,
T50.4X5D Adverse effect of drugs affecting uric acid metabolism, subsequent
subsequent encounter
encounter
T50.A25S Adverse effect of mixed bacterial vaccines without a pertussis component,
T50.4X5S Adverse effect of drugs affecting uric acid metabolism, sequela
sequela
T50.5X5A Adverse effect of appetite depressants, initial encounter
T50.A95A Adverse effect of other bacterial vaccines, initial encounter
T50.5X5D Adverse effect of appetite depressants, subsequent encounter
T50.A95D Adverse effect of other bacterial vaccines, subsequent encounter
T50.5X5S Adverse effect of appetite depressants, sequela
T50.A95S Adverse effect of other bacterial vaccines, sequela
T50.6X5A Adverse effect of antidotes and chelating agents, initial encounter
T50.B15A Adverse effect of smallpox vaccines, initial encounter
T50.6X5D Adverse effect of antidotes and chelating agents, subsequent encounter
T50.B15D Adverse effect of smallpox vaccines, subsequent encounter
T50.6X5S Adverse effect of antidotes and chelating agents, sequela
T50.B15S Adverse effect of smallpox vaccines, sequela
T50.7X5A Adverse effect of analeptics and opioid receptor antagonists, initial
T50.B95A Adverse effect of other viral vaccines, initial encounter
encounter
T50.B95D Adverse effect of other viral vaccines, subsequent encounter
T50.7X5D Adverse effect of analeptics and opioid receptor antagonists,
T50.B95S Adverse effect of other viral vaccines, sequela
subsequent encounter
T50.Z15A Adverse effect of immunoglobulin, initial encounter
T50.7X5S Adverse effect of analeptics and opioid receptor antagonists, sequela
T50.Z15D Adverse effect of immunoglobulin, subsequent encounter
T50.8X5A Adverse effect of diagnostic agents, initial encounter
T50.Z15S Adverse effect of immunoglobulin, sequela
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 14 of 15)
CPT Code: 86003
Data Source: Local Coverage Determination for
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T50.Z95A Adverse effect of other vaccines and biological substances, initial
encounter
T50.Z95D Adverse effect of other vaccines and biological substances, subsequent
encounter
T50.Z95S Adverse effect of other vaccines and biological substances, sequela
T50.905A Adverse effect of unspecified drugs, medicaments and biological
substances, initial encounter
T50.905D Adverse effect of unspecified drugs, medicaments and biological
substances, subsequent encounter
T50.905S Adverse effect of unspecified drugs, medicaments and biological
substances, sequela
T50.995A Adverse effect of other drugs, medicaments and biological substances,
initial encounter
T50.995D Adverse effect of other drugs, medicaments and biological substances,
subsequent encounter
T50.995S Adverse effect of other drugs, medicaments and biological substances,
sequela
T63.061A - T63.094S - Opens in a new window Toxic effect of venom of other North
and South American snake, accidental (unintentional), initial encounter Toxic effect of venom of other snake, undetermined, sequela
T63.111A - T63.124S - Opens in a new window Toxic effect of venom of gila
monster, accidental (unintentional), initial encounter - Toxic effect of
venom of other venomous lizard, undetermined, sequela
T63.191A - T63.194S - Opens in a new window Toxic effect of venom of other
reptiles, accidental (unintentional), initial encounter - Toxic effect of
venom of other reptiles, undetermined, sequela
T63.2X1A - T63.2X4S - Opens in a new window Toxic effect of venom of scorpion,
accidental (unintentional), initial encounter - Toxic effect of venom of
scorpion, undetermined, sequela
T63.311A - T63.334S - Opens in a new window Toxic effect of venom of black widow
spider, accidental (unintentional), initial encounter - Toxic effect of venom
of brown recluse spider, undetermined, sequela
T63.391A - T63.394S - Opens in a new window Toxic effect of venom of other spider,
accidental (unintentional), initial encounter - Toxic effect of venom of other
spider, undetermined, sequela
T63.411A - T63.484S - Opens in a new window Toxic effect of venom of centipedes
and venomous millipedes, accidental (unintentional), initial encounter Toxic effect of venom of other arthropod, undetermined, sequela
T63.511A - T63.514S - Opens in a new window Toxic effect of contact with stingray,
accidental (unintentional), initial encounter - Toxic effect of contact with
stingray, undetermined, sequela
T63.591A - T63.594S - Opens in a new window Toxic effect of contact with other
venomous fish, accidental (unintentional), initial encounter - Toxic effect of
contact with other venomous fish, undetermined, sequela
T63.611A - T63.634S - Opens in a new window Toxic effect of contact with Portugese
Man-o-war, accidental (unintentional), initial encounter - Toxic effect of
contact with sea anemone, undetermined, sequela
T63.691A - T63.694S - Opens in a new window Toxic effect of contact with other
venomous marine animals, accidental (unintentional), initial encounter Toxic effect of contact with other venomous marine animals,
undetermined, sequela
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
RAST Type Tests (pg. 15 of 15)
CPT Code: 86003
Data Source: Local Coverage Determination for
RAST Type Tests (L33591)
LCD Description: Radioallergosorbent test (RAST), fluoroallergosorbent test (FAST), and multiple antigen simultaneous tests are in vitro techniques for determining whether a patient's serum
contains IgE antibodies against specific allergens of clinical importance. As with any allergy testing, the need for such tests is based on the findings during a complete history and physical
examination of the patient.
The multiple antigen simultaneous testing technique is similar to the RAST/FAST techniques in that it depends upon the existence of allergic antibodies in the blood of the patient being tested.
With the multiple antigen simultaneous test system, several antigens may be used to test for specific IgE simultaneously.
ELISA (enzyme-linked immunosorbent assay) is another in vitro method of allergy testing for specific IgE antibodies against allergens. This method is also a variation of RAST.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T63.711A - T63.714S - Opens in a new window Toxic effect of contact with
venomous marine plant, accidental (unintentional), initial encounter Toxic effect of contact with venomous marine plant, undetermined,
sequela
T63.791A - T63.794S - Opens in a new window Toxic effect of contact with other
venomous plant, accidental (unintentional), initial encounter - Toxic
effect of contact with other venomous plant, undetermined, sequela
T63.811A - T63.834S - Opens in a new window Toxic effect of contact with
venomous frog, accidental (unintentional), initial encounter - Toxic effect
of contact with other venomous amphibian, undetermined, sequela
T63.891A - T63.894S - Opens in a new window Toxic effect of contact with other
venomous animals, accidental (unintentional), initial encounter - Toxic
effect of contact with other venomous animals, undetermined, sequela
T78.00XA - T78.00XS - Opens in a new window Anaphylactic reaction due to
unspecified food, initial encounter - Anaphylactic reaction due to
unspecified food, sequela
T78.01XA - T78.09XS - Opens in a new window Anaphylactic reaction due to
peanuts, initial encounter - Anaphylactic reaction due to other food
products, sequela
T78.2XXA - T78.3XXS - Opens in a new window Anaphylactic shock, unspecified,
initial encounter - Angioneurotic edema, sequela
T78.40XA - T78.40XS - Opens in a new window Allergy, unspecified, initial
encounter - Allergy, unspecified, sequela
T78.49XA - T78.49XS - Opens in a new window Other allergy, initial encounter Other allergy, sequela
T88.6XXA - T88.6XXS - Opens in a new window Anaphylactic reaction due to
adverse effect of correct drug or medicament properly administered,
initial encounter - Anaphylactic reaction due to adverse effect of correct
drug or medicament properly administered, sequela
Z91.048
Other nonmedicinal substance allergy status
Z91.09
Other allergy status, other than to drugs and biological substances
Utilization Guidelines:
It is expected that these services would be performed as indicated by current medical
literature and/or standards of practice. When services are performed in excess of
established parameters, they may be subject to review for medical necessity.
Limitations:
The following tests are considered to be not medically necessary and will be denied.
* ELISA/Act qualitative antibody testing- This testing is used to determine in vitro
reaction to various foods and relies on lymphocyte blastogenesis in response to
certain food antigens.
* LMRA (Lymphocyte Mitogen Response Assays) by ELISA/Act
* IgG and IgG subclass antibody tests for food allergy do not have clinical relevance,
are not validated, lack sufficient quality control, and should not be performed.
CPT codes 86001 and 86005 are not covered services.
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-10-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.
Last Updated:
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.
10/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Urine Drug Testing (pg. 1 of 10)
CPT Codes: G0479, G0480, G0481, G0482, and G0483 Data Source: Local Coverage Determination
(LCD): Urine Drug Testing (L36037)
LCD Description: Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and
making treatment decisions. This policy details: The appropriate indications and expected frequency of testing for safe medication management of prescribed substances in
risk stratified pain management patients and/or in identifying and treating substance use disorders. Designates documentation, by the clinician in the patient’s medical record,
of medical necessity for, and testing ordered on an individual patient basis; Provides an overview of presumptive urine drug testing (UDT) and definitive UDT testing by
various methodologies.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
F20.89
Other schizophrenia
F55.0
Abuse
of antacids
E87.2
Acidosis
F55.1
Abuse
of herbal or folk remedies
F10.20
Alcohol dependence, uncomplicated
F55.2
Abuse of laxatives
F11.20
Opioid dependence, uncomplicated
F55.3
Abuse of steroids or hormones
F11.220 Opioid dependence with intoxication, uncomplicated
F55.4
Abuse of vitamins
F11.221 Opioid dependence with intoxication delirium
F55.8
Abuse of other non-psychoactive substances
F11.222 Opioid dependence with intoxication with perceptual disturbance
G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not
F11.229 Opioid dependence with intoxication, unspecified
intractable, with status epilepticus
F11.23
Opioid dependence with withdrawal
G40.309
Generalized
idiopathic epilepsy and epileptic syndromes, not intractable,
F11.24
Opioid dependence with opioid-induced mood disorder
without status epilepticus
F11.250 Opioid dependence with opioid-induced psychotic disorder with
G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with
delusions
status epilepticus
F11.251 Opioid dependence with opioid-induced psychotic disorder with
G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable,
hallucinations
without status epilepticus
F11.259 Opioid dependence with opioid-induced psychotic disorder,
G40.401
Other
generalized epilepsy and epileptic syndromes, not intractable, with
unspecified
status epilepticus
F11.281 Opioid dependence with opioid-induced sexual dysfunction
G40.409 Other generalized epilepsy and epileptic syndromes, not intractable, without
F11.282 Opioid dependence with opioid-induced sleep disorder
status epilepticus
F11.288 Opioid dependence with other opioid-induced disorder
G40.411
Other
generalized epilepsy and epileptic syndromes, intractable, with status
F11.29
Opioid dependence with unspecified opioid-induced disorder
epilepticus
F18.10
Inhalant abuse, uncomplicated
G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without
F18.120 Inhalant abuse with intoxication, uncomplicated
status epilepticus
F18.90
Inhalant use, unspecified, uncomplicated
G40.901 Epilepsy, unspecified, not intractable, with status epilepticus
F19.20
other psychoactive substance dependence, uncomplicated
G40.909 Epilepsy, unspecified, not intractable, without status epilepticus
F20.0
Paranoid schizophrenia
G40.911 Epilepsy, unspecified, intractable, with status epilepticus
F20.1
Disorganized schizophrenia
G40.919 Epilepsy, unspecified, intractable, without status epilepticus
F20.2
Catatonic schizophrenia
G89.29
Other chronic pain
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-10-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.
Last Updated:
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.
1/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Urine Drug Testing (pg. 2 of 10)
CPT Codes: G0479, G0480, G0481, G0482, and G0483 Data Source: Local Coverage Determination
(LCD): Urine Drug Testing (L36037)
LCD Description: Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body
and making treatment decisions. This policy details: The appropriate indications and expected frequency of testing for safe medication management of prescribed
substances in risk stratified pain management patients and/or in identifying and treating substance use disorders. Designates documentation, by the clinician in the
patient’s medical record, of medical necessity for, and testing ordered on an individual patient basis; Provides an overview of presumptive urine drug testing (UDT) and
definitive UDT testing by various methodologies.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s
medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM
book should be used as a complete reference.
M47.896 Other spondylosis, lumbar region
G89.4
Chronic pain syndrome
M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
I44.0
Atrioventricular block, first degree
M47.818 Spondylosis without myelopathy or radiculopathy, sacral and
I44.1
Atrioventricular block, second degree
sacrococcygeal region
I44.30
Unspecified atrioventricular block
M47.891 Other spondylosis, occipito-atlanto-axial region
I45.81
Long QTsyndrome
M47.892 Other spondylosis, cervical region
I47.0
Re-entry ventricular arrhythmia
M47.893 Other spondylosis, cervicothoracic region
I47.1
Supraventricular tachycardia
M47.896 Other spondylosis, lumbar region
I47.2
Ventricular tachycardia
M47.897 Other spondylosis, lumbosacral region
I49.2
Junctional premature depolarization
M47.898 Other spondylosis, sacral and sacrococcygeal region
M25.50
Pain in unspecified joint
M51.14
Intervertebral disc disorders with radiculopathy, thoracic region
M47.21
Other spondylosis with radiculopathy, occipito-atlanto-axial region
M51.15
Intervertebral disc disorders with radiculopathy, thoracolumbar region
M47.22
Other spondylosis with radiculopathy, cervical region
M51.16
Intervertebral disc disorders with radiculopathy, lumbar region
M47.23
Other spondylosis with radiculopathy, cervicothoracic region
M51.17
Intervertebral disc disorders with radiculopathy, lumbosacral region
M47.26
Other spondylosis with radiculopathy, lumbar region
M51.36
Other intervertebral disc degeneration, lumbar region
M47.27
Other spondylosis with radiculopathy, lumbosacral region
M51.37
Other intervertebral disc degeneration, lumbosacral region
M47.28
Other spondylosis with radiculopathy, sacral and sacrococcygeal region
M54.14
Radiculopathy, thoracic region
M47.811 Spondylosis without myelopathy or radiculopathy, occipito-atlanto-axial
M54.15
Radiculopathy, thoracolumbar region
region
M54.16
Radiculopathy, lumbar region
M47.812 Spondylosis without myelopathy or radiculopathy, cervical region
M54.17
Radiculopathy, lumbosacral region
M47.813 Spondylosis without myelopathy or radiculopathy, cervicothoracic region
M54.18
Radiculopathy, sacral and sacrococcygeal region
M47.816 Spondylosis without myelopathy or radiculopathy, lumbar region
M54.2
Cervicalgia
M47.817 Spondylosis without myelopathy or radiculopathy, lumbosacral region
M54.5
Low back pain
M47.818 Spondylosis without myelopathy or radiculopathy, sacral and
M60.811 Other myositis, right shoulder
sacrococcygeal region
M60.812 Other myositis, left shoulder
M47.891 Other spondylosis, occipito-atlanto-axial region
M60.821 Other myositis, right upper arm
M47.892 Other spondylosis, cervical region
M60.822 Other myositis, left upper arm
M47.893 Other spondylosis, cervicothoracic region
M60.831 Other myositis, right forearm
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-10-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.
Last Updated:
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.
1/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Urine Drug Testing (pg. 3 of 10)
CPT Codes: G0479, G0480, G0481, G0482, and G0483 Data Source: Local Coverage Determination
(LCD): Urine Drug Testing (L36037)
LCD Description: Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and
making treatment decisions. This policy details: T he appropriate indications and expected frequency of testing for safe medication management of prescribed substances in
risk stratified pain management patients and/or in identifying and treating substance use disorders. Designates documentation, by the clinician in the patient’s medical
record, of medical necessity for, and testing ordered on an individual patient basis; Provides an overview of presumptive urine drug testing (UDT) and definitive UDT testing
by various methodologies.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
R40.2124 Coma scale, eyes open, to pain, 24 hours or more after hospital
M60.832
M60.841
M60.842
M60.851
M60.852
M60.861
M60.862
M60.871
M60.872
M60.88
M60.89
M60.9
M79.1
M79.2
M79.7
R40.0
R40.1
R40.20
R40.2110
R40.2111
R40.2112
R40.2113
R40.2114
R40.2120
R40.2121
R40.2122
R40.2123
Other myositis, left forearm
Other myositis, right hand
Other myositis, left hand
Other myositis, right thigh
Other myositis, left thigh
Other myositis, right lower leg
Other myositis, left lower leg
Other myositis, right ankle and foot
Other myositis, left ankle and foot
Other myositis, other site
Other myositis, multiple sites
Myositis, unspecified
Myalgia
Neuralgia and neuritis, unspecified
Fibromyalgia
Somnolence
Stupor
Unspecified coma
Coma scale, eyes open, never, unspecified time
Coma scale, eyes open, never, in the field [EMT or ambulance]
Coma scale, eyes open, never, at arrival to emergency department
Coma scale, eyes open, never, at hospital admission
Coma scale, eyes open, never, 24 hours or more after hospital admission
Coma scale, eyes open, to pain, unspecified time
Coma scale, eyes open, to pain, in the field [EMT or ambulance]
Coma scale, eyes open, to pain, at arrival to emergency department
Coma scale, eyes open, to pain, at hospital admission
admission
R40.2210 Coma scale, best verbal response, none, unspecified time
R40.2211 Coma scale, best verbal response, none, in the field [EMTor
ambulance]
R40.2212 Coma scale, best verbal response, none, at arrival to emergency
department
R40.2213 Coma scale, best verbal response, none, at hospital admission
R40.2214 Coma scale, best verbal response, none, 24 hours or more after
hospital admission
R40.2220 Coma scale, best verbal response, incomprehensible words,
unspecified time
R40.2221 Coma scale, best verbal response, incomprehensible words, in the field
[EMT or ambulance]
R40.2222 Coma scale, best verbal response, incomprehensible words, at arrival
to emergency department
R40.2223 Coma scale, best verbal response, incomprehensible words, at hospital
admission
R40.2224 Coma scale, best verbal response, incomprehensible words, 24 hours
or more after hospital admission
R40.2310 Coma scale, best motor response, none, unspecified time
R40.2311 Coma scale, best motor response, none, in the field [EMT or
ambulance]
R40.2312 Coma scale, best motor response, none, at arrival to emergency
department
R40.2313 Coma scale, best motor response, none, at hospital admission
R40.2314 Coma scale, best motor response, none, 24 hours or more after hospital
admission
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-10-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.
Last Updated:
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.
1/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Urine Drug Testing (pg. 4 of 10)
CPT Codes: G0479, G0480, G0481, G0482, and G0483 Data Source: Local Coverage Determination
(LCD): Urine Drug Testing (L36037)
LCD Description: Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and
making treatment decisions. This policy details: The appropriate indications and expected frequency of testing for safe medication management of prescribed substances in
risk stratified pain management patients and/or in identifying and treating substance use disorders. Designates documentation, by the clinician in the patient’s medical
record, of medical necessity for, and testing ordered on an individual patient basis; Provides an overview of presumptive urine drug testing (UDT) and definitive UDT testing
by various methodologies.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T39.092A Poisoning by salicylates, intentional self-harm, initial encounter
R40.2320 Coma scale, best motor response, extension, unspecified time
T39.093A Poisoning by salicylates, assault, initial encounter
R40.2321 Coma scale, best motor response, extension, in the field [EMT or
T39.094A Poisoning by salicylates, undetermined, initial encounter
ambulance]
T39.1X1A Poisoning by 4-Aminophenol derivatives, accidental (unintentional),
R40.2322 Coma scale, best motor response, extension, at arrival to emergency
initial encounter
department
T39.1X2A Poisoning by 4-Aminophenol derivatives, intentional self-harm, initial
R40.2323 Coma scale, best motor response, extension, at hospital admission
encounter
R40.2324 Coma scale, best motor response, extension, 24 hours or more after
T39.1X3A Poisoning by 4-Aminophenol derivatives, assault, initial encounter
hospital admission
T39.1X4A Poisoning by 4-Aminophenol derivatives, undetermined, initial
R40.2340 Coma scale, best motor response, flexion withdrawal, unspecified time
encounter
R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or
T39.2X1A Poisoning by pyrazolone derivatives, accidental (unintentional), initial
ambulance]
encounter
R40.2342 Coma scale, best motor response, flexion withdrawal, at arrival to
T39.2X2A Poisoning by pyrazolone derivatives, intentional self-harm, initial
emergency department
encounter
R40.2343 Coma scale, best motor response, flexion withdrawal, at hospital
T39.2X3A Poisoning by pyrazolone derivatives, assault, initial encounter
admission
T39.2X4A Poisoning by pyrazolone derivatives, undetermined, initial encounter
R40.2344 Coma scale, best motor response, flexion withdrawal, 24 hours or more
T39.311A Poisoning by propionic acid derivatives, accidental (unintentional),
after hospital admission
initial encounter
R44.0
Auditory hallucinations
T39.312A Poisoning by propionic acid derivatives, intentional self-harm, initial
R44.2
Other hallucinations
encounter
R44.3
Hallucinations, unspecified
T39.313A Poisoning by propionic acid derivatives, assault, initial encounter
R56.9
Unspecified convulsions
T39.314A Poisoning by propionic acid derivatives, undetermined, initial
T39.011A Poisoning by aspirin, accidental (unintentional), initial encounter
encounter
T39.012A Poisoning by aspirin, intentional self-harm, initial encounter
T39.391A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID],
T39.013A Poisoning by aspirin, assault, initial encounter
accidental (unintentional), initial encounter
T39.014A Poisoning by aspirin, undetermined, initial encounter
T39.392A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID],
T39.091A Poisoning by salicylates, accidental (unintentional), initial encounter
intentional self-harm, initial encounter
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-10-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.
Last Updated:
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.
1/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Urine Drug Testing (pg. 5 of 10)
CPT Codes: G0479, G0480, G0481, G0482, and G0483 Data Source: Local Coverage Determination
(LCD): Urine Drug Testing (L36037)
LCD Description: Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and
making treatment decisions. This policy details: The appropriate indications and expected frequency of testing for safe medication management of prescribed substances in
risk stratified pain management patients and/or in identifying and treating substance use disorders. Designates documentation, by the clinician in the patient’s medical
record, of medical necessity for, and testing ordered on an individual patient basis; Provides an overview of presumptive urine drug testing (UDT) and definitive UDT testing
by various methodologies.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T40.601A Poisoning by unspecified narcotics, accidental (unintentional), initial
T39.393A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID],
encounter
assault, initial encounter
T40.602A Poisoning by unspecified narcotics, intentional self-harm, initial
T39.394A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID],
encounter
undetermined, initial encounter
T40.603A Poisoning by unspecified narcotics, assault, initial encounter
T40.0X1A Poisoning by opium, accidental (unintentional), initial encounter
T40.604A Poisoning by unspecified narcotics, undetermined, initial encounter
T40.0X2A Poisoning by opium, intentional self-harm, initial encounter
T40.691A Poisoning by other narcotics, accidental (unintentional), initial
T40.0X3A Poisoning by opium, assault, initial encounter
encounter
T40.0X4A Poisoning by opium, undetermined, initial encounter
T40.692A Poisoning by other narcotics, intentional self-harm, initial encounter
T40.1X1A Poisoning by heroin, accidental (unintentional), initial encounter
T40.693A Poisoning by other narcotics, assault, initial encounter
T40.1X2A Poisoning by heroin, intentional self-harm, initial encounter
T40.694A Poisoning by other narcotics, undetermined, initial encounter
T40.1X3A Poisoning by heroin, assault, initial encounter
T40.7X1A Poisoning by cannabis (derivatives), accidental (unintentional), initial
T40.1X4A Poisoning by heroin, undetermined, initial encounter
encounter
T40.2X1A Poisoning by other opioids, accidental (unintentional), initial encounter
T40.7X2A Poisoning by cannabis (derivatives), intentional self-harm, initial
T40.2X2A Poisoning by other opioids, intentional self-harm, initial encounter
encounter
T40.2X3A Poisoning by other opioids, assault, initial encounter
T40.7X3A Poisoning by cannabis (derivatives), assault, initial encounter
T40.2X4A Poisoning by other opioids, undetermined, initial encounter
T40.7X4A Poisoning by cannabis (derivatives), undetermined, initial encounter
T40.3X1A Poisoning by methadone, accidental (unintentional), initial encounter
T40.8X1A Poisoning by lysergide [LSD], accidental (unintentional), initial
T40.3X2A Poisoning by methadone, intentional self-harm, initial encounter
encounter
T40.3X3A Poisoning by methadone, assault, initial encounter
T40.8X2A Poisoning by lysergide [LSD], intentional self-harm, initial encounter
T40.3X4A Poisoning by methadone, undetermined, initial encounter
T40.8X3A Poisoning by lysergide [LSD], assault, initial encounter
T40.4X1A Poisoning by other synthetic narcotics, accidental (unintentional), initial
T40.8X4A Poisoning by lysergide [LSD], undetermined, initial encounter
encounter
T40.901A Poisoning by unspecified psychodysleptics [hallucinogens], accidental
T40.4X2A Poisoning by other synthetic narcotics, intentional self-harm, initial
(unintentional), initial encounter
encounter
T40.902A Poisoning by unspecified psychodysleptics [hallucinogens], intentional
T40.4X3A Poisoning by other synthetic narcotics, assault, initial encounter
self- harm, initial encounter
T40.4X4A Poisoning by other synthetic narcotics, undetermined, initial encounter
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-10-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.
Last Updated:
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.
1/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Urine Drug Testing (pg. 6 of 10)
CPT Codes: G0479, G0480, G0481, G0482, and G0483 Data Source: Local Coverage Determination
(LCD): Urine Drug Testing (L36037)
LCD Description: Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and
making treatment decisions. This policy details: The appropriate indications and expected frequency of testing for safe medication management of prescribed substances in
risk stratified pain management patients and/or in identifying and treating substance use disorders. Designates documentation, by the clinician in the patient’s medical
record, of medical necessity for, and testing ordered on an individual patient basis; Provides an overview of presumptive urine drug testing (UDT) and definitive UDT testing
by various methodologies.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T42.4X4A Poisoning by benzodiazepines, undetermined, initial encounter
T40.903A Poisoning by unspecified psychodysleptics [hallucinogens], assault, initial
T42.6X1A Poisoning by other antiepileptic and sedative-hypnotic drugs,
encounter
accidental (unintentional), initial encounter
T40.904A Poisoning by unspecified psychodysleptics [hallucinogens], undetermined,
T42.6X2A Poisoning by other antiepileptic and sedative-hypnotic drugs,
initial encounter
intentional self-harm, initial encounter
T40.991A Poisoning by other psychodysleptics [hallucinogens], accidental
T42.6X3A Poisoning by other antiepileptic and sedative-hypnotic drugs, assault,
(unintentional), initial encounter
initial encounter
T40.992A Poisoning by other psychodysleptics [hallucinogens], intentional selfT42.6X4A Poisoning by other antiepileptic and sedative-hypnotic drugs,
harm, initial encounter
undetermined, initial encounter
T40.993A Poisoning by other psychodysleptics [hallucinogens], assault, initial
T42.71XA Poisoning by unspecified antiepileptic and sedative-hypnotic drugs,
encounter
accidental (unintentional), initial encounter
T40.994A Poisoning by other psychodysleptics [hallucinogens], undetermined,
T42.72XA Poisoning by unspecified antiepileptic and sedative-hypnotic drugs,
initial encounter
intentional self-harm, initial encounter
T42.0X1A Poisoning by hydantoin derivatives, accidental (unintentional), initial
T42.73XA Poisoning by unspecified antiepileptic and sedative-hypnotic drugs,
encounter
assault, initial encounter
T42.0X2A Poisoning by hydantoin derivatives, intentional self-harm, initial
T42.74XA Poisoning by unspecified antiepileptic and sedative-hypnotic drugs,
encounter
undetermined, initial encounter
T42.0X3A Poisoning by hydantoin derivatives, assault, initial encounter
T43.011A Poisoning by tricyclic antidepressants, accidental (unintentional), initial
T42.0X4A Poisoning by hydantoin derivatives, undetermined, initial encounter
encounter
T42.3X1A Poisoning by barbiturates, accidental (unintentional), initial encounter
T43.012A Poisoning by tricyclic antidepressants, intentional self-harm, initial
T42.3X2A Poisoning by barbiturates, intentional self-harm, initial encounter
encounter
T42.3X3A Poisoning by barbiturates, assault, initial encounter
T43.013A Poisoning by tricyclic antidepressants, assault, initial encounter
T42.3X4A Poisoning by barbiturates, undetermined, initial encounter
T43.014A Poisoning by tricyclic antidepressants, undetermined, initial encounter
T42.4X1A Poisoning by benzodiazepines, accidental (unintentional), initial
T43.021A Poisoning by tetracyclic antidepressants, accidental (unintentional),
encounter
initial encounter
T42.4X2A Poisoning by benzodiazepines, intentional self-harm, initial encounter
T43.022A Poisoning by tetracyclic antidepressants, intentional self-harm, initial
T42.4X3A Poisoning by benzodiazepines, assault, initial encounter
encounter
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-10-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.
Last Updated:
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.
1/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Urine Drug Testing (pg. 7 of 10)
CPT Codes: G0479, G0480, G0481, G0482, and G0483 Data Source: Local Coverage Determination
(LCD): Urine Drug Testing (L36037)
LCD Description. Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and
making treatment decisions. This policy details: The appropriate indications and expected frequency of testing for safe medication management of prescribed substances in
risk stratified pain management patients and/or in identifying and treating substance use disorders. Designates documentation, by the clinician in the patient’s medical
record, of medical necessity for, and testing ordered on an individual patient basis; Provides an overview of presumptive urine drug testing (UDT) and definitive UDT testing
by various methodologies
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T43.222A Poisoning by selective serotonin reuptake inhibitors, intentional selfharm, initial encounter
T43.023A Poisoning by tetracyclic antidepressants, assault, initial encounter
T43.223A Poisoning by selective serotonin reuptake inhibitors, assault, initial
T43.024A Poisoning by tetracyclic antidepressants, undetermined, initial encounter
encounter
T43.1X1A Poisoning by monoamine-oxidase-inhibitor antidepressants,
T43.224A Poisoning by selective serotonin reuptake inhibitors, undetermined,
accidental (unintentional), initial encounter
initial encounter
T43.1X2A Poisoning by monoamine-oxidase-inhibitor antidepressants,
T43.291A
Poisoning
by other antidepressants, accidental (unintentional), initial
intentional self-harm, initial encounter
encounter
T43.1X3A Poisoning by monoamine-oxidase-inhibitor antidepressants, assault,
T43.292A Poisoning by other antidepressants, intentional self-harm, initial
initial encounter
encounter
T43.1X4A Poisoning by monoamine-oxidase-inhibitor antidepressants,
T43.293A
Poisoning
by other antidepressants, assault, initial encounter
undetermined, initial encounter
T43.294A Poisoning by other antidepressants, undetermined, initial encounter
T43.201A Poisoning by unspecified antidepressants, accidental (unintentional),
T43.3X1A Poisoning by phenothiazine antipsychotics and neuroleptics,
initial encounter
accidental (unintentional), initial encounter
T43.202A Poisoning by unspecified antidepressants, intentional self-harm, initial
T43.3X2A Poisoning by phenothiazine antipsychotics and neuroleptics,
encounter
intentional self-harm, initial encounter
T43.203A Poisoning by unspecified antidepressants, assault, initial encounter
T43.3X3A
Poisoning
by phenothiazine antipsychotics and neuroleptics, assault,
T43.204A Poisoning by unspecified antidepressants, undetermined, initial
initial encounter
encounter
T43.3X4A Poisoning by phenothiazine antipsychotics and neuroleptics,
T43.211A Poisoning by selective serotonin and norepinephrine reuptake
undetermined, initial encounter
inhibitors, accidental (unintentional), initial encounter
T43.4X1A
Poisoning
by butyrophenone and thiothixene neuroleptics, accidental
T43.212A Poisoning by selective serotonin and norepinephrine reuptake
(unintentional), initial encounter
inhibitors, intentional self-harm, initial encounter
T43.4X2A Poisoning by butyrophenone and thiothixene neuroleptics, intentional
T43.213A Poisoning by selective serotonin and norepinephrine reuptake
self-harm, initial encounter
inhibitors, assault, initial encounter
T43.4X3A Poisoning by butyrophenone and thiothixene neuroleptics, assault,
T43.214A Poisoning by selective serotonin and norepinephrine reuptake
initial encounter
inhibitors, undetermined, initial encounter
T43.4X4A
Poisoning
by butyrophenone and thiothixene neuroleptics,
T43.221A Poisoning by selective serotonin reuptake inhibitors, accidental
undetermined, initial encounter
(unintentional), initial encounter
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-10-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.
Last Updated:
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.
1/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Urine Drug Testing (pg. 8 of 10)
CPT Codes: G0479, G0480, G0481, G0482, and G0483 Data Source: Local Coverage Determination
(LCD): Urine Drug Testing (L36037)
LCD Description: : Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and
making treatment decisions. This policy details: The appropriate indications and expected frequency of testing for safe medication management of prescribed substances in
risk stratified pain management patients and/or in identifying and treating substance use disorders. Designates documentation, by the clinician in the patient’s medical record,
of medical necessity for, and testing ordered on an individual patient basis; Provides an overview of presumptive urine drug testing (UDT) and definitive UDT testing by
various methodologies.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
T43.614A Poisoning by caffeine, undetermined, initial encounter
T43.501A Poisoning by unspecified antipsychotics and neuroleptics, accidental
(unintentional), initial encounter
T43.502A Poisoning by unspecified antipsychotics and neuroleptics, intentional
self-harm, initial encounter
T43.503A Poisoning by unspecified antipsychotics and neuroleptics, assault,
initial encounter
T43.504A Poisoning by unspecified antipsychotics and neuroleptics,
undetermined, initial encounter
T43.591A Poisoning by other antipsychotics and neuroleptics, accidental
(unintentional), initial encounter
T43.592A Poisoning by other antipsychotics and neuroleptics, intentional selfharm, initial encounter
T43.593A Poisoning by other antipsychotics and neuroleptics, assault, initial
encounter
T43.594A Poisoning by other antipsychotics and neuroleptics, undetermined,
initial encounter
T43.601A Poisoning by unspecified psychostimulants, accidental (unintentional),
initial encounter
T43.602A Poisoning by unspecified psychostimulants, intentional self-harm,
initial encounter
T43.603A Poisoning by unspecified psychostimulants, assault, initial encounter
T43.604A Poisoning by unspecified psychostimulants, undetermined, initial
encounter
T43.611A Poisoning by caffeine, accidental (unintentional), initial encounter
T43.612A Poisoning by caffeine, intentional self-harm, initial encounter
T43.613A Poisoning by caffeine, assault, initial encounter
T43.621A Poisoning by amphetamines, accidental (unintentional), initial
encounter
T43.622A Poisoning by amphetamines, intentional self-harm, initial encounter
T43.623A Poisoning by amphetamines, assault, initial encounter
T43.624A Poisoning by amphetamines, undetermined, initial encounter
T43.631A Poisoning by methylphenidate, accidental (unintentional), initial
encounter
T43.632A Poisoning by methylphenidate, intentional self-harm, initial encounter
T43.633A Poisoning by methylphenidate, assault, initial encounter
T43.634A Poisoning by methylphenidate, undetermined, initial encounter
T43.691A Poisoning by other psychostimulants, accidental (unintentional), initial
encounter
T43.692A Poisoning by other psychostimulants, intentional self-harm, initial
encounter
T43.693A Poisoning by other psychostimulants, assault, initial encounter
T43.694A Poisoning by other psychostimulants, undetermined, initial encounter
T43.8X1A Poisoning by other psychotropic drugs, accidental (unintentional),
initial encounter
T43.8X2A Poisoning by other psychotropic drugs, intentional self-harm, initial
encounter
T43.8X3A Poisoning by other psychotropic drugs, assault, initial encounter
T43.8X4A Poisoning by other psychotropic drugs, undetermined, initial encounter
T43.91XA Poisoning by unspecified psychotropic drug, accidental
(unintentional), initial encounter
T43.92XA Poisoning by unspecified psychotropic drug, intentional self-harm, initial
encounter
T43.93XA Poisoning by unspecified psychotropic drug, assault, initial encounter
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-10-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.
Last Updated:
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.
1/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Urine Drug Testing (pg. 9 of 10)
Data Source: Local Coverage Determination
CPT Codes: G0479, G0480, G0481, G0482, and G0483
(LCD): Urine Drug Testing (L36037)
LCD Description: Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and
making treatment decisions. This policy details: The appropriate indications and expected frequency of testing for safe medication management of prescribed substances in
risk stratified pain management patients and/or in identifying and treating substance use disorders. Designates documentation, by the clinician in the patient’s medical
record, of medical necessity for, and testing ordered on an individual patient basis; Provides an overview of presumptive urine drug testing (UDT) and definitive UDT testing
by various methodologies
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
Z51.81
Encounter for therapeutic drug level monitoring
T43.94XA Poisoning by unspecified psychotropic drug, undetermined, initial
encounter
T45.0X1A Poisoning by antiallergic and antiemetic drugs, accidental
(unintentional), initial encounter
T45.0X2A Poisoning by antiallergic and antiemetic drugs, intentional self-harm,
initial encounter
T45.0X3A Poisoning by antiallergic and antiemetic drugs, assault, initial
encounter
T45.0X4A Poisoning by antiallergic and antiemetic drugs, undetermined, initial
encounter
T46.0X1A Poisoning by cardiac-stimulant glycosides and drugs of similar action,
accidental (unintentional), initial encounter
T46.0X2A Poisoning by cardiac-stimulant glycosides and drugs of similar action,
intentional self-harm, initial encounter
T46.0X3A Poisoning by cardiac-stimulant glycosides and drugs of similar action,
assault, initial encounter
T46.0X4A Poisoning by cardiac-stimulant glycosides and drugs of similar action,
undetermined, initial encounter
T50.901A Poisoning by unspecified drugs, medicaments and biological
substances, accidental (unintentional), initial encounter
T50.902A Poisoning by unspecified drugs, medicaments and biological
substances, intentional self-harm, initial encounter
T50.903A Poisoning by unspecified drugs, medicaments and biological
substances, assault, initial encounter
T50.904A Poisoning by unspecified drugs, medicaments and biological
substances, undetermined, initial encounter
Z79.3
Long term (current) use of hormonal contraceptives
Z79.891 Long term (current) use of opiate analgesic
Z79.899 Other long term (current) drug therapy
Z91.19
Patient's noncompliance with other medical treatment and regimen
A.Presumptive UDT Panels
Presumptive UDT testing may be ordered as a panel because the Medicare billing
codes (G0431 and G0434) are defined on a “per patient encounter” basis regardless of
the number of analytes tested. Presumptive UDT orders should be individualized based
on clinical history and risk assessment, and must be documented in the medical record.
B.Definitive UDT Panels
At the current time, physician-directed definitive profile testing is reasonable and
necessary when ordered for a particular patient based upon historical use and
community trends. However, the same physician-defined profile is not reasonable and
necessary for every patient in a physician’s practice. Definitive UDT orders should be
individualized based on clinical history and risk assessment, and must be documented
in the medical record.
Limitations of Presumptive UDT:
Presumptive UDT testing is limited due to:
◦Primarily screens for drug classes rather than specific drugs, and therefore, the
practitioner may not be able to determine if a different drug within the same class is
causing the positive result;
◦Produces erroneous results due to cross-reactivity with other compounds or does not
detect all drugs within a drug class;
◦Given that not all prescription medications or synthetic/analog drugs are detectable
and/or have assays available, it is unclear as to whether other drugs are present when
some tests are reported as positive;
◦Cut-off may be too high to detect presence of a drug
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-10-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.
Last Updated:
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.
1/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Urine Drug Testing (pg. 10 of 10)
Data Source: Local Coverage Determination
CPT Codes: G0479, G0480, G0481, G0482, and G0483
(LCD): Urine Drug Testing (L36037)
LCD Description: Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and
making treatment decisions. This policy details: The appropriate indications and expected frequency of testing for safe medication management of prescribed substances in
risk stratified pain management patients and/or in identifying and treating substance use disorders. Designates documentation, by the clinician in the patient’s medical
record, of medical necessity for, and testing ordered on an individual patient basis; Provides an overview of presumptive urine drug testing (UDT) and definitive UDT testing
by various methodologies
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
Frequency of Definitive UDT for SUD:
Depending on the patient’s specific substance use history, definitive UDT to accurately determine the specific drugs in the patient’s system may be necessary.
Definitive testing may be ordered when accurate and reliable results are necessary to integrate treatment decisions and clinical assessment. The frequency and the
rational for definitive UDT must be documented in the patient’s medical record.
a. For patients with 0 to 30 consecutive days of abstinence, definitive UDT is expected at a frequency not to exceed 1 physician-directed testing profile in one week.
More than 1 physician-directed testing profile in one week is not reasonable and necessary and is not covered by Medicare.
b. For patients with 31 to 90 consecutive days of abstinence, definitive UDT is expected at a frequency of 1-3 physician-directed testing profiles in one month. More
than 3 UDT in one month is not reasonable and necessary and is not covered by Medicare.
c. For patients with > 90 day of consecutive abstinence, definitive UDT is expected at a frequency of 1-3 physician-directed testing profiles in three months. More
than 3 definitive UDT in 3 months is not reasonable and necessary and is not covered by Medicare."
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-10-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.
Last Updated:
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.
1/01/16
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Data Source: Local Coverage Determination
Vitamin D Assay Testing (pg. 1of 10)
CPT Code: 82306
for Vitamin D Assay Testing (L33556)
LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to
hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these
services.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
Group 1 Codes:
E20.0
E20.8
E20.9
E21.0
E21.1
E21.2
E21.3
E55.0
E55.9
E67.3
E83.30
E83.31
E83.32
E83.39
E83.51
E83.52
E89.2
M80.00XA
M80.00XD
M80.00XG
M80.00XK
M80.00XP
M80.00XS
Idiopathic hypoparathyroidism
Other hypoparathyroidism
Hypoparathyroidism, unspecified
Primary hyperparathyroidism
Secondary hyperparathyroidism, not elsewhere classified
Other hyperparathyroidism
Hyperparathyroidism, unspecified
Rickets, active
Vitamin d deficiency, unspecified
Hypervitaminosis D
Disorder of phosphorus metabolism, unspecified
Familial hypophosphatemia
Hereditary vitamin d-dependent rickets (type 1) (type 2)
Other disorders of phosphorus metabolism
Hypocalcemia
Hypercalcemia
Postprocedural hypoparathyroidism
Age-related osteoporosis with current pathological fracture, unspecified
site, initial encounter for fracture
Age-related osteoporosis with current pathological fracture, unspecified
site, subsequent encounter for fracture with routine healing
Age-related osteoporosis with current pathological fracture, unspecified
site, subsequent encounter for fracture with delayed healing
Age-related osteoporosis with current pathological fracture, unspecified
site, subsequent encounter for fracture with nonunion
Age-related osteoporosis with current pathological fracture, unspecified
site, subsequent encounter for fracture with malunion
Age-related osteoporosis with current pathological fracture,
unspecified site, sequela
M80.011A Age-related osteoporosis with current pathological fracture, right
shoulder, initial encounter for fracture
M80.011D Age-related osteoporosis with current pathological fracture, right
shoulder, subsequent encounter for fracture with routine healing
M80.011G Age-related osteoporosis with current pathological fracture, right
shoulder, subsequent encounter for fracture with delayed healing
M80.011K Age-related osteoporosis with current pathological fracture, right
shoulder, subsequent encounter for fracture with nonunion
M80.011P Age-related osteoporosis with current pathological fracture, right
shoulder, subsequent encounter for fracture with malunion
M80.011S Age-related osteoporosis with current pathological fracture, right
shoulder, sequela
M80.012A Age-related osteoporosis with current pathological fracture, left
shoulder, initial encounter for fracture
M80.012D Age-related osteoporosis with current pathological fracture, left
shoulder, subsequent encounter for fracture with routine healing
M80.012G Age-related osteoporosis with current pathological fracture, left
shoulder, subsequent encounter for fracture with delayed healing
M80.012K Age-related osteoporosis with current pathological fracture, left shoulder,
subsequent encounter for fracture with nonunion
M80.012P Age-related osteoporosis with current pathological fracture, left shoulder,
subsequent encounter for fracture with malunion
M80.012S Age-related osteoporosis with current pathological fracture, left shoulder,
sequela
M80.019A Age-related osteoporosis with current pathological fracture,
unspecified shoulder, initial encounter for fracture
M80.019D Age-related osteoporosis with current pathological fracture,
unspecified shoulder, subsequent encounter for fracture with
routine healing
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-10-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.
Last Updated:
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.
12/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Vitamin D Assay Testing (pg. 2 of 10)
Data Source: Local Coverage Determination
CPT Code: 82306
for Vitamin D Assay Testing (L33556)
LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to
hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these
services.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
M80.019G Age-related osteoporosis with current pathological fracture,
unspecified shoulder, subsequent encounter for fracture with
delayed healing
M80.019K Age-related osteoporosis with current pathological fracture,
unspecified shoulder, subsequent encounter for fracture with
nonunion
M80.019P Age-related osteoporosis with current pathological fracture,
unspecified shoulder, subsequent encounter for fracture with
malunion
M80.019S Age-related osteoporosis with current pathological fracture,
unspecified shoulder, sequela
M80.021A Age-related osteoporosis with current pathological fracture, right
humerus, initial encounter for fracture
M80.021D Age-related osteoporosis with current pathological fracture, right
humerus, subsequent encounter for fracture with routine healing
M80.021G Age-related osteoporosis with current pathological fracture, right
humerus, subsequent encounter for fracture with delayed healing
M80.021K Age-related osteoporosis with current pathological fracture, right
humerus, subsequent encounter for fracture with nonunion
M80.021P Age-related osteoporosis with current pathological fracture, right
humerus, subsequent encounter for fracture with malunion
M80.021S Age-related osteoporosis with current pathological fracture, right
humerus, sequela
M80.022A Age-related osteoporosis with current pathological fracture, left
humerus, initial encounter for fracture
M80.022D Age-related osteoporosis with current pathological fracture, left
humerus, subsequent encounter for fracture with routine healing
M80.022G Age-related osteoporosis with current pathological fracture, left
humerus, subsequent encounter for fracture with delayed healing
M80.022K Age-related osteoporosis with current pathological fracture, left humerus,
subsequent encounter for fracture with nonunion
M80.022P Age-related osteoporosis with current pathological fracture, left humerus,
subsequent encounter for fracture with malunion
M80.022S Age-related osteoporosis with current pathological fracture, left humerus,
squela
M80.029A Age-related osteoporosis with current pathological fracture, unspecified
humerus, initial encounter for fracture
M80.029D Age-related osteoporosis with current pathological fracture, unspecified
humerus, subsequent encounter for fracture with routine healing
M80.029G Age-related osteoporosis with current pathological fracture,
unspecified humerus, subsequent encounter for fracture with delayed
healing
M80.029K Age-related osteoporosis with current pathological fracture, unspecified
humerus, subsequent encounter for fracture with nonunion
M80.029P Age-related osteoporosis with current pathological fracture, unspecified
humerus, subsequent encounter for fracture with malunion
M80.029S Age-related osteoporosis with current pathological fracture, unspecified
humerus, sequela
M80.031A Age-related osteoporosis with current pathological fracture, right forearm,
initial encounter for fracture
M80.031D Age-related osteoporosis with current pathological fracture, right forearm,
subsequent encounter for fracture with routine healing
M80.031G Age-related osteoporosis with current pathological fracture, right forearm,
subsequent encounter for fracture with delayed healing
M80.031K Age-related osteoporosis with current pathological fracture, right forearm,
subsequent encounter for fracture with nonunion
M80.031P Age-related osteoporosis with current pathological fracture, right forearm,
subsequent encounter for fracture with malunion
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-10-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.
Last Updated:
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.
12/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Vitamin D Assay Testing (pg. 3 of 10)
Data Source: Local Coverage Determination
CPT Code: 82306
for Vitamin D Assay Testing (L33556)
LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to
hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these
services.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
M80.041D Age-related osteoporosis with current pathological fracture, right
M80.031S Age-related osteoporosis with current pathological fracture, right
hand, subsequent encounter for fracture with routine healing
forearm, sequela
M80.041G
Age-related
osteoporosis with current pathological fracture, right
M80.032A Age-related osteoporosis with current pathological fracture, left forearm,
hand, subsequent encounter for fracture with delayed healing
initial encounter for fracture
M80.041K Age-related osteoporosis with current pathological fracture, right
M80.032D Age-related osteoporosis with current pathological fracture, left forearm,
hand, subsequent encounter for fracture with nonunion
subsequent encounter for fracture with routine healing
M80.041P
Age-related osteoporosis with current pathological fracture, right
M80.032G Age-related osteoporosis with current pathological fracture, left forearm,
hand, subsequent encounter for fracture with malunion
subsequent encounter for fracture with delayed healing
M80.041S Age-related osteoporosis with current pathological fracture, right hand,
M80.032K Age-related osteoporosis with current pathological fracture, left forearm,
sequela
subsequent encounter for fracture with nonunion
M80.042A Age-related osteoporosis with current pathological fracture, left hand,
M80.032P Age-related osteoporosis with current pathological fracture, left forearm,
initial encounter for fracture
subsequent encounter for fracture with malunion
M80.042D
Age-related
osteoporosis with current pathological fracture, left hand,
M80.032S Age-related osteoporosis with current pathological fracture, left forearm,
subsequent encounter for fracture with routine healing
sequela
M80.042G Age-related osteoporosis with current pathological fracture, left hand,
M80.039A Age-related osteoporosis with current pathological fracture, unspecified
subsequent encounter for fracture with delayed healing
forearm, initial encounter for fracture
M80.042K
Age-related
osteoporosis with current pathological fracture, left hand,
M80.039D Age-related osteoporosis with current pathological fracture, unspecified
subsequent encounter for fracture with nonunion
forearm, subsequent encounter for fracture with routine healing
M80.042S Age-related osteoporosis with current pathological fracture, left hand,
M80.039G Age-related osteoporosis with current pathological fracture, unspecified
sequela
forearm, subsequent encounter for fracture with delayed healing
M80.049A Age-related osteoporosis with current pathological fracture, unspecified
M80.039K Age-related osteoporosis with current pathological fracture, unspecified
hand, initial encounter for fracture
forearm, subsequent encounter for fracture with nonunion
M80.049D
Age-related
osteoporosis with current pathological fracture, unspecified
M80.039P Age-related osteoporosis with current pathological fracture, unspecified
hand, subsequent encounter for fracture with routine healing
forearm, subsequent encounter for fracture with malunion
M80.049G Age-related osteoporosis with current pathological fracture, unspecified
M80.039S Age-related osteoporosis with current pathological fracture, unspecified
hand, subsequent encounter for fracture with delayed healing
forearm, sequela
M80.049K
Age-related
osteoporosis with current pathological fracture, unspecified
M80.041A Age-related osteoporosis with current pathological fracture, right hand,
and, subsequent encounter for fracture with nonunion
initial encounter for fracture
M80.049P Age-related osteoporosis with current pathological fracture, unspecified
hand, subsequent encounter for fracture with malunion
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-10-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.
Last Updated:
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.
12/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Vitamin D Assay Testing (pg. 4 of 10)
Data Source: Local Coverage Determination
CPT Code: 82306
for Vitamin D Assay Testing (L33556)
LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to
hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these
services.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
M80.049S Age-related osteoporosis with current pathological fracture, unspecified
hand, sequela
M80.051A Age-related osteoporosis with current pathological fracture, right femur,
initial encounter for fracture
M80.051D Age-related osteoporosis with current pathological fracture, right femur,
subsequent encounter for fracture with routine healing
M80.051G Age-related osteoporosis with current pathological fracture, right femur,
subsequent encounter for fracture with delayed healing
M80.051K Age-related osteoporosis with current pathological fracture, right femur,
subsequent encounter for fracture with nonunion
M80.051P Age-related osteoporosis with current pathological fracture, right femur,
subsequent encounter for fracture with malunion
M80.051S Age-related osteoporosis with current pathological fracture, right femur,
sequela
M80.052A Age-related osteoporosis with current pathological fracture, left femur,
initial encounter for fracture
M80.052D Age-related osteoporosis with current pathological fracture, left femur,
subsequent encounter for fracture with routine healing
M80.052G Age-related osteoporosis with current pathological fracture, left femur,
subsequent encounter for fracture with delayed healing
M80.052K Age-related osteoporosis with current pathological fracture, left femur,
subsequent encounter for fracture with nonunion
M80.052P Age-related osteoporosis with current pathological fracture, left femur,
subsequent encounter for fracture with malunion
M80.052S Age-related osteoporosis with current pathological fracture, left femur,
sequela
M80.059A Age-related osteoporosis with current pathological fracture, unspecified
femur, initial encounter for fracture
M80.059D Age-related osteoporosis with current pathological fracture, unspecified
femur, subsequent encounter for fracture with routine healing
M80.059G Age-related osteoporosis with current pathological fracture, unspecified
femur, subsequent encounter for fracture with delayed healing
M80.059K Age-related osteoporosis with current pathological fracture, unspecified
femur, subsequent encounter for fracture with nonunion
M80.059P Age-related osteoporosis with current pathological fracture, unspecified
femur, subsequent encounter for fracture with malunion
M80.059S Age-related osteoporosis with current pathological fracture, unspecified
femur, sequela
M80.061A Age-related osteoporosis with current pathological fracture, right lower
leg, initial encounter for fracture
M80.061D Age-related osteoporosis with current pathological fracture, right lower
leg, subsequent encounter for fracture with routine healing
M80.061G Age-related osteoporosis with current pathological fracture, right lower
leg, subsequent encounter for fracture with delayed healing
M80.061K Age-related osteoporosis with current pathological fracture, right lower
leg, subsequent encounter for fracture with nonunion
M80.061P Age-related osteoporosis with current pathological fracture, right lower
leg, subsequent encounter for fracture with malunion
M80.061S Age-related osteoporosis with current pathological fracture, right lower
leg, sequela
M80.062A Age-related osteoporosis with current pathological fracture, left lower leg,
initial encounter for fracture
M80.062D Age-related osteoporosis with current pathological fracture, left lower
leg, subsequent encounter for fracture with routine healing
M80.062G Age-related osteoporosis with current pathological fracture, left lower leg,
subsequent encounter for fracture with delayed healing
M80.062K Age-related osteoporosis with current pathological fracture, left lower leg,
subsequent encounter for fracture with nonunion
M80.062P Age-related osteoporosis with current pathological fracture, left
lower leg, subsequent encounter for fracture with malunion
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-10-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.
Last Updated:
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.
12/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Data Source: Local Coverage Determination
Vitamin D Assay Testing (pg. 5 of 10)
CPT Code: 82306
for Vitamin D Assay Testing (L33556)
LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to
hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these
services.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
M80.062S Age-related osteoporosis with current pathological fracture, left lower leg,
sequela
M80.069A Age-related osteoporosis with current pathological fracture, unspecified
lower leg, initial encounter for fracture
M80.069D Age-related osteoporosis with current pathological fracture, unspecified
lower leg, subsequent encounter for fracture with routine healing
M80.069G Age-related osteoporosis with current pathological fracture, unspecified
lower leg, subsequent encounter for fracture with delayed healing
M80.069K Age-related osteoporosis with current pathological fracture, unspecified
lower leg, subsequent encounter for fracture with nonunion
M80.069P Age-related osteoporosis with current pathological fracture, unspecified
lower leg, subsequent encounter for fracture with malunion
M80.069S Age-related osteoporosis with current pathological fracture, unspecified
lower leg, sequela
M80.071A Age-related osteoporosis with current pathological fracture, right ankle
and foot, initial encounter for fracture
M80.071D Age-related osteoporosis with current pathological fracture, right ankle
and foot, subsequent encounter for fracture with routine healing
M80.071G Age-related osteoporosis with current pathological fracture, right ankle
and foot, subsequent encounter for fracture with delayed healing
M80.071K Age-related osteoporosis with current pathological fracture, right ankle
and foot, subsequent encounter for fracture with nonunion
M80.071P Age-related osteoporosis with current pathological fracture, right ankle
and foot, subsequent encounter for fracture with malunion
M80.071S Age-related osteoporosis with current pathological fracture, right ankle
and foot, sequela
M80.072A Age-related osteoporosis with current pathological fracture, left ankle
and foot, initial encounter for fracture
M80.072D Age-related osteoporosis with current pathological fracture, left ankle
and foot, subsequent encounter for fracture with routine healing
M80.072G Age-related osteoporosis with current pathological fracture, left ankle
and foot, subsequent encounter for fracture with delayed healing
M80.072K Age-related osteoporosis with current pathological fracture, left ankle
and foot, subsequent encounter for fracture with nonunion
M80.079G Age-related osteoporosis with current pathological fracture, unspecified
ankle and foot, subsequent encounter for fracture with delayed healing
M80.079K Age-related osteoporosis with current pathological fracture, unspecified
ankle and foot, subsequent encounter for fracture with nonunion
M80.079P Age-related osteoporosis with current pathological fracture, unspecified
ankle and foot, subsequent encounter for fracture with malunion
M80.079S Age-related osteoporosis with current pathological fracture, unspecified
ankle and foot, sequela
M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e),
initial encounter for fracture
M80.08XD Age-related osteoporosis with current pathological fracture, vertebra(e),
subsequent encounter for fracture with routine healing
M80.08XG Age-related osteoporosis with current pathological fracture, vertebra(e),
subsequent encounter for fracture with delayed healing
M80.08XK Age-related osteoporosis with current pathological fracture, vertebra(e),
subsequent encounter for fracture with nonunion
M80.08XP Age-related osteoporosis with current pathological fracture, vertebra(e),
subsequent encounter for fracture with malunion
M80.08XS Age-related osteoporosis with current pathological fracture, vertebra(e),
sequela
M80.80XA Other osteoporosis with current pathological fracture, unspecified
site, initial encounter for fracture
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-10-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.
Last Updated:
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.
12/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Data Source: Local Coverage Determination
Vitamin D Assay Testing (pg. 6 of 10)
CPT Code: 82306
for Vitamin D Assay Testing (L33556)
LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to
hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these
services.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
M80.80XD Other osteoporosis with current pathological fracture, unspecified site,
subsequent encounter for fracture with routine healing
M80.80XG Other osteoporosis with current pathological fracture, unspecified site,
subsequent encounter for fracture with delayed healing
M80.80XK Other osteoporosis with current pathological fracture, unspecified site,
subsequent encounter for fracture with nonunion
M80.80XP Other osteoporosis with current pathological fracture, unspecified site,
subsequent encounter for fracture with malunion
M80.80XS Other osteoporosis with current pathological fracture, unspecified site,
sequela
M80.811A Other osteoporosis with current pathological fracture, right shoulder,
initial encounter for fracture
M80.811D Other osteoporosis with current pathological fracture, right shoulder,
subsequent encounter for fracture with routine healing
M80.811G Other osteoporosis with current pathological fracture, right shoulder,
subsequent encounter for fracture with delayed healing
M80.811K Other osteoporosis with current pathological fracture, right shoulder,
subsequent encounter for fracture with nonunion
M80.811P Other osteoporosis with current pathological fracture, right shoulder,
subsequent encounter for fracture with malunion
M80.811S Other osteoporosis with current pathological fracture, right shoulder,
sequela
M80.812A Other osteoporosis with current pathological fracture, left shoulder,
initial encounter for fracture
M80.812D Other osteoporosis with current pathological fracture, left shoulder,
subsequent encounter for fracture with routine healing
M80.812G Other osteoporosis with current pathological fracture, left
shoulder, subsequent encounter for fracture with delayed healing
M80.812K Other osteoporosis with current pathological fracture, left
shoulder, subsequent encounter for fracture with nonunion
M80.812P Other osteoporosis with current pathological fracture, left shoulder,
subsequent encounter for fracture with malunion
M80.812S Other osteoporosis with current pathological fracture, left shoulder,
sequela
M80.819A Other osteoporosis with current pathological fracture, unspecified
shoulder, initial encounter for fracture
M80.819D Other osteoporosis with current pathological fracture, unspecified
shoulder, subsequent encounter for fracture with routine healing
M80.819G Other osteoporosis with current pathological fracture, unspecified
shoulder, subsequent encounter for fracture with delayed healing
M80.819K Other osteoporosis with current pathological fracture, unspecified
shoulder, subsequent encounter for fracture with nonunion
M80.819P Other osteoporosis with current pathological fracture, unspecified
shoulder, subsequent encounter for fracture with malunion
M80.819S Other osteoporosis with current pathological fracture, unspecified
shoulder, sequela
M80.821A Other osteoporosis with current pathological fracture, right humerus,
initial encounter for fracture
M80.821D Other osteoporosis with current pathological fracture, right humerus,
subsequent encounter for fracture with routine healing
M80.821G Other osteoporosis with current pathological fracture, right humerus,
subsequent encounter for fracture with delayed healing
M80.821K Other osteoporosis with current pathological fracture, right humerus,
subsequent encounter for fracture with nonunion
M80.831A Other osteoporosis with current pathological fracture, right forearm, initial
encounter for fracture
M80.831D Other osteoporosis with current pathological fracture, right forearm,
subsequent encounter for fracture with routine healing
M80.831G Other osteoporosis with current pathological fracture, right forearm,
subsequent encounter for fracture with delayed healing
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-10-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.
Last Updated:
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.
12/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Data Source: Local Coverage Determination
Vitamin D Assay Testing (pg. 7 of 10)
CPT Code: 82306
for Vitamin D Assay Testing (L33556)
LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to
hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these
services.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
M80.841D Other osteoporosis with current pathological fracture, right hand,
M80.831K Other osteoporosis with current pathological fracture, right forearm,
subsequent encounter for fracture with routine healing
subsequent encounter for fracture with nonunion
M80.841G Other osteoporosis with current pathological fracture, right hand,
M80.831P Other osteoporosis with current pathological fracture, right forearm,
subsequent encounter for fracture with delayed healing
subsequent encounter for fracture with malunion
M80.841K Other osteoporosis with current pathological fracture, right hand,
M80.831S Other osteoporosis with current pathological fracture, right forearm,
subsequent encounter for fracture with nonunion
sequela
M80.841P Other osteoporosis with current pathological fracture, right hand,
M80.832A Other osteoporosis with current pathological fracture, left forearm, initial
subsequent encounter for fracture with malunion
encounter for fracture
M80.841S Other osteoporosis with current pathological fracture, right hand, sequela
M80.832D Other osteoporosis with current pathological fracture, left forearm,
M80.842A Other osteoporosis with current pathological fracture, left hand, initial
subsequent encounter for fracture with routine healing
encounter for fracture
M80.832G Other osteoporosis with current pathological fracture, left forearm,
M80.842D Other osteoporosis with current pathological fracture, left hand,
subsequent encounter for fracture with delayed healing
subsequent encounter for fracture with routine healing
M80.832K Other osteoporosis with current pathological fracture, left forearm,
M80.842G Other osteoporosis with current pathological fracture, left hand,
subsequent encounter for fracture with nonunion
M80.842K Other osteoporosis with current pathological fracture, left hand,
M80.832P Other osteoporosis with current pathological fracture, left forearm,
subsequent encounter for fracture with nonunion
subsequent encounter for fracture with malunion
M80.842P Other osteoporosis with current pathological fracture, left hand,
M80.832S Other osteoporosis with current pathological fracture, left forearm,
subsequent encounter for fracture with malunion
sequela
M80.842S Other osteoporosis with current pathological fracture, left hand, sequela
M80.839A Other osteoporosis with current pathological fracture, unspecified
M80.849A Other osteoporosis with current pathological fracture, unspecified
forearm, initial encounter for fracture
hand, initial encounter for fracture subsequent encounter for fracture with
M80.839D Other osteoporosis with current pathological fracture, unspecified
delayed healing
forearm, subsequent encounter for fracture with routine healing
M80.849D Other osteoporosis with current pathological fracture, unspecified hand,
M80.839G Other osteoporosis with current pathological fracture, unspecified
subsequent encounter for fracture with routine healing
forearm, subsequent encounter for fracture with delayed healing
M80.849G Other osteoporosis with current pathological fracture, unspecified hand,
M80.839K Other osteoporosis with current pathological fracture, unspecified
subsequent encounter for fracture with delayed healing
forearm, subsequent encounter for fracture with nonunion
M80.849K Other osteoporosis with current pathological fracture, unspecified hand,
M80.839S Other osteoporosis with current pathological fracture, unspecified
subsequent encounter for fracture with nonunion
forearm, sequela
M80.849P Other osteoporosis with current pathological fracture, unspecified hand,
M80.841A Other osteoporosis with current pathological fracture, right hand, initial
subsequent encounter for fracture with malunion
encounter for fracture
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-10-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.
Last Updated:
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.
12/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Data Source: Local Coverage Determination
Vitamin D Assay Testing (pg. 8 of 10)
CPT Code: 82306
for Vitamin D Assay Testing (L33556)
LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to
hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these
services.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
M80.859G Other osteoporosis with current pathological fracture, unspecified femur,
M80.849S Other osteoporosis with current pathological fracture, unspecified hand,
subsequent encounter for fracture with delayed healing
sequela
M80.859K Other osteoporosis with current pathological fracture, unspecified femur,
M80.851A Other osteoporosis with current pathological fracture, right femur, initial
subsequent encounter for fracture with nonunion
encounter for fracture
M80.859P Other osteoporosis with current pathological fracture, unspecified femur,
M80.851D Other osteoporosis with current pathological fracture, right femur,
subsequent encounter for fracture with malunion
subsequent encounter for fracture with routine healing
M80.859S Other osteoporosis with current pathological fracture, unspecified femur,
M80.851G Other osteoporosis with current pathological fracture, right femur,
sequela
subsequent encounter for fracture with delayed healing
M80.861A Other osteoporosis with current pathological fracture, right lower leg,
M80.851K Other osteoporosis with current pathological fracture, right femur,
initial encounter for fracture
subsequent encounter for fracture with nonunion
M80.861D Other osteoporosis with current pathological fracture, right lower leg,
M80.851P Other osteoporosis with current pathological fracture, right femur,
subsequent encounter for fracture with routine healing
subsequent encounter for fracture with malunion
M80.861G Other osteoporosis with current pathological fracture, right lower leg,
M80.851S Other osteoporosis with current pathological fracture, right femur,
subsequent encounter for fracture with delayed healing
sequela
M80.861K Other osteoporosis with current pathological fracture, right lower leg,
M80.852A Other osteoporosis with current pathological fracture, left femur, initial
subsequent encounter for fracture with nonunion
encounter for fracture
M80.861P Other osteoporosis with current pathological fracture, right lower leg,
M80.852D Other osteoporosis with current pathological fracture, left femur,
subsequent encounter for fracture with malunion
subsequent encounter for fracture with routine healing
M80.861S Other osteoporosis with current pathological fracture, right lower leg,
M80.852G Other osteoporosis with current pathological fracture, left femur,
sequela
subsequent encounter for fracture with delayed healing
M80.862A Other osteoporosis with current pathological fracture, left lower leg,
M80.852K Other osteoporosis with current pathological fracture, left femur,
initial encounter for fracture
subsequent encounter for fracture with nonunion
M80.862D Other osteoporosis with current pathological fracture, left lower leg,
M80.852P Other osteoporosis with current pathological fracture, left femur,
subsequent encounter for fracture with routine healing
subsequent encounter for fracture with malunion
M80.862G Other osteoporosis with current pathological fracture, left lower leg,
M80.852S Other osteoporosis with current pathological fracture, left femur, sequela
subsequent encounter for fracture with delayed healing
M80.859A Other osteoporosis with current pathological fracture, unspecified femur,
M80.862K Other osteoporosis with current pathological fracture, left lower leg,
initial encounter for fracture
subsequent encounter for fracture with nonunion
M80.859D Other osteoporosis with current pathological fracture, unspecified femur,
M80.862P Other osteoporosis with current pathological fracture, left lower leg,
subsequent encounter for fracture with routine healing
subsequent encounter for fracture with malunion
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-10-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.
Last Updated:
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.
12/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Vitamin D Assay Testing (pg. 9 of 10)
Data Source: Local Coverage Determination
CPT Code: 82306
for Vitamin D Assay Testing (L33556)
LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to
hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these
services.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
M80.872G Other osteoporosis with current pathological fracture, left ankle and foot,
M80.862S Other osteoporosis with current pathological fracture, left lower leg,
subsequent encounter for fracture with delayed healing
sequela
M80.872K Other osteoporosis with current pathological fracture, left ankle and foot,
M80.869A Other osteoporosis with current pathological fracture, unspecified lower
subsequent encounter for fracture with nonunion
leg, initial encounter for fracture
M80.872P Other osteoporosis with current pathological fracture, left ankle and foot,
M80.869D Other osteoporosis with current pathological fracture, unspecified lower
subsequent encounter for fracture with malunion
leg, subsequent encounter for fracture with routine healing
M80.872S Other osteoporosis with current pathological fracture, left ankle and foot,
M80.869G Other osteoporosis with current pathological fracture, unspecified lower
sequela
leg, subsequent encounter for fracture with delayed healing
M80.879A Other osteoporosis with current pathological fracture, unspecified ankle
M80.869K Other osteoporosis with current pathological fracture, unspecified lower
and foot, initial encounter for fracture
leg, subsequent encounter for fracture with nonunion
M80.879D Other osteoporosis with current pathological fracture, unspecified ankle
M80.869P Other osteoporosis with current pathological fracture, unspecified lower
and foot, subsequent encounter for fracture with routine healing
leg, subsequent encounter for fracture with malunion
M80.879G Other osteoporosis with current pathological fracture, unspecified ankle
M80.869S Other osteoporosis with current pathological fracture, unspecified lower
and foot, subsequent encounter for fracture with delayed healing
leg, sequela
M80.879K Other osteoporosis with current pathological fracture, unspecified ankle
M80.871A Other osteoporosis with current pathological fracture, right ankle and
and foot, subsequent encounter for fracture with nonunion
foot, initial encounter for fracture
M80.879P Other osteoporosis with current pathological fracture, unspecified ankle
M80.871D Other osteoporosis with current pathological fracture, right ankle and
and foot, subsequent encounter for fracture with malunion
foot, subsequent encounter for fracture with routine healing
M80.879S Other osteoporosis with current pathological fracture, unspecified ankle
M80.871G Other osteoporosis with current pathological fracture, right ankle and
and foot, sequela
foot, subsequent encounter for fracture with delayed healing
M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial
M80.871K Other osteoporosis with current pathological fracture, right ankle and
encounter for fracture
foot, subsequent encounter for fracture with nonunion
M80.88XD Other osteoporosis with current pathological fracture, vertebra(e),
M80.871P Other osteoporosis with current pathological fracture, right ankle and
subsequent encounter for fracture with routine healing
foot, subsequent encounter for fracture with malunion
M80.88XG Other osteoporosis with current pathological fracture, vertebra(e),
M80.871S Other osteoporosis with current pathological fracture, right ankle and
subsequent encounter for fracture with delayed healing
foot, sequela
M80.88XK Other osteoporosis with current pathological fracture, vertebra(e),
M80.872A Other osteoporosis with current pathological fracture, left ankle and foot,
subsequent encounter for fracture with nonunion
initial encounter for fracture
M80.88XP Other osteoporosis with current pathological fracture, vertebra(e),
M80.872D Other osteoporosis with current pathological fracture, left ankle and foot,
subsequent encounter for fracture with malunion
subsequent encounter for fracture with routine healing
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-10-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.
Last Updated:
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.
12/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT
Data Source: Local Coverage Determination
Vitamin D Assay Testing (pg. 10 of 10)
CPT Code: 82306
for Vitamin D Assay Testing (L33556)
LCD Description: Vitamin D is a hormone, synthesized by the skin and metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to
hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these
services.
ICD-10-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis
must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient’s medical
record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-10-CM book
should be used as a complete reference.
M80.88XS Other osteoporosis with current pathological fracture, vertebra(e),
sequela
M81.0
Age-related osteoporosis without current pathological fracture
M81.6
localized osteoporosis [lequesne]
M81.8
Other osteoporosis without current pathological fracture
M83.0
Puerperal osteomalacia
M83.1
Senile osteomalacia
M83.2
Adult osteomalacia due to malabsorption
M83.3
Adult osteomalacia due to malnutrition
M83.4
Aluminum bone disease
M83.5
Other drug-induced osteomalacia in adults
M83.8
Other adult osteomalacia
M83.9
Adult osteomalacia, unspecified
M85.80* Other specified disorders of bone density and structure, unspecified site
M85.831* Other specified disorders of bone density and structure, right forearm
M85.832* Other specified disorders of bone density and structure, left forearm
M85.839* Other specified disorders of bone density and structure, unspecified
forearm
M85.851* Other specified disorders of bone density and structure, right thigh
M85.852* Other specified disorders of bone density and structure, left thigh
M85.859* Other specified disorders of bone density and structure, unspecified
thigh
M85.88* Other specified disorders of bone density and structure, other site
M85.89* Other specified disorders of bone density and structure, multiple sites
M85.9*
Disorder of bone density and structure, unspecified
M89.9*
Disorder of bone, unspecified
N18.3
Chronic kidney disease, stage 3 (moderate)
N18.4
Chronic kidney disease, stage 4 (severe)
N18.5
Chronic kidney disease, stage 5
N18.6
N25.81
End stage renal disease
Secondary hyperparathyroidism of renal origin
Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation:
**Osteopenia should be reported using ICD-10-CM codes M85.80, M85.831M85.839, M89.851-M85.859, M85.88, M85.89, M85.9 or M89.9
Indications: Measurement of vitamin D levels is indicated for patients with:
•chronic kidney disease stage III or greater;
•osteoporosis;
•osteomalacia;
•osteopenia;
•hypocalcemia;
•hypercalcemia;
•hypoparathyroidism;
•hyperparathyroidism;
•rickets; and
•vitamin D deficiency to monitor the efficacy of replacement therapy.
Limitations: For Medicare beneficiaries, screening tests are governed by
statute. Vitamin D testing may not be used for routine screening.
Once a beneficiary has been shown to be vitamin D deficient, further testing
is medically necessary only to ensure adequate replacement has been
accomplished. Thereafter, annual testing may be appropriate depending
upon the indication and other mitigating factors
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-10-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.
Last Updated:
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.
12/01/15
All third party marks - ® and ™ - are the property of their respective owners. © 2016 Quest Diagnostics Incorporated. All rights reserved