Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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 • • • • • • • • • • • • • • • • • • • • • • • 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