Medicare National and Local Coverage Determination … · Medicare National and Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT 10/01/16

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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

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 patients symptoms or conditions and must be consistent with documentation in the patients 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.

Medicare National and Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT

10/01/16

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

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

http://questnet1.qdx.com/index.hthttps://www.cms.gov/Medicare/Coverage/CoverageGenInfo/Downloads/manual201610_ICD10.pdf

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This list was compiled from Medicares Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.

Note: If the patients 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.

Please direct any questions regarding coding to the payer being billed.



Medicare Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT

B-type Natriuretic Peptide (BNP) Testing CPT Code: 83880

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 patients 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 Acute on chronic combined systolic (congestive) and diastolic (congestive)

heart failure

I50.9 Heart failure, unspecified

J44.0 Chronic obstructive pulmonary disease with acute lower respiratory infection

J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation

J45.901 Unspecified asthma with (acute) exacerbation

J98.01 Acute bronchospasm

R06.00 Dyspnea, unspecified

R06.01 Orthopnea

R06.02 Shortness of breath

R06.09 Other forms of dyspnea

R06.2 Wheezing

R06.82 Tachypnea, not elsewhere classified

R06.89 Other abnormalities of breathing

R06.9 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)

Data Source: Local Coverage Determination (LCD): B-type Natriuretic Peptide (BNP) Testing (L33573)

07/01/16

http://questnet1.qdx.com/index.hthttps://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33573&ContrId=299&ver=7&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAIAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33573&ContrId=299&ver=7&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAIAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33573&ContrId=299&ver=7&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAIAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33573&ContrId=299&ver=7&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAIAAAAAAA%3d%3d&

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Combined Ovarian Cancer Biomarker Tests CPT Code: 81500, 81503, 84999

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 2-

microglobulin, 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.


must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patients

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.

Data Source: Local Coverage Determination for Combined Ovarian Cancer Biomarker Tests (L33588)

10/01/15

http://questnet1.qdx.com/index.hthttp://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=32965&ContrId=180&ver=8&ContrVer=1&CntrctrSelected=180*1&Cntrctr=180&name=National+Government+Services,+Inc.+(13102,+MAC+-+Part+B)&DocType=Active&LCntrctr=54*1|55*1|56*1|52*1|53*1|51*1|57*1|63*1|89*1|64*1|65*1|192*1|1*1|2*1|178*1|180*1|179*1|181*1|182*1|183*1|138*1&bc=AgACAAIAAAAAAA==&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33588&ContrId=299&ver=4&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAIAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33588&ContrId=299&ver=4&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAIAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=33588&ContrId=299&ver=4&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAIAAAAAAA%3d%3d&

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Genomic Sequence Analysis Panels in the Treatment

of Non-Small Cell Lung Cancer CPT Code: 81445

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.


must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patients 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 Malignant neoplasm of trachea

C34.00 Malignant neoplasm of unspecified main bronchus

C34.01 Malignant neoplasm of right main bronchus

C34.02 Malignant neoplasm of left main bronchus

C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung

C34.11 Malignant neoplasm of upper lobe, right bronchus or lung

C34.12 Malignant neoplasm of upper lobe, left bronchus or lung

C34.2 Malignant neoplasm of middle lobe, bronchus or lung

C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung

C34.31 Malignant neoplasm of lower lobe, right bronchus or lung

C34.32 Malignant neoplasm of lower lobe, left bronchus or lung

C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung

C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung

C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung

C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung

C34.91 Malignant neoplasm of unspecified part of right bronchus or lung

C34.92 Malignant neoplasm of unspecified part of left bronchus or lung

C38.4 Malignant neoplasm of pleura

C45.0 Mesothelioma of pleura

Data Source: Genomic Sequence Analysis Panels in the Treatment of Non-Small Cell Lung Cancer

(L36376)

4/01/16

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.

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Heavy Metal Testing (pg. 1 of 10) CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,

83655, 83785, 83825, 83885, 84255, 84285, 84630

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 patients 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 Other specified mental disorders due to known physiological condition

F11.121 Opioid abuse with intoxication delirium

F11.122 Opioid abuse with intoxication with perceptual disturbance

F11.14 Opioid abuse with opioid-induced mood disorder

F11.188 Opioid abuse with other opioid-induced disorder

F11.221 Opioid dependence with intoxication delirium

F11.24 Opioid dependence with opioid-induced mood disorder

F11.288 Opioid dependence with other opioid-induced disorder

F11.921 Opioid use, unspecified with intoxication delirium

F11.929 Opioid use, unspecified with intoxication, unspecified

F11.94 Opioid use, unspecified with opioid-induced mood disorder

F11.988 Opioid use, unspecified with other opioid-induced disorder

F12.121 Cannabis abuse with intoxication delirium

F12.129 Cannabis abuse with intoxication, unspecified

F12.159 Cannabis abuse with psychotic disorder, unspecified

F12.188 Cannabis abuse with other cannabis-induced disorder

F12.221 Cannabis dependence with intoxication delirium

F12.229 Cannabis dependence with intoxication, unspecified

F12.288 Cannabis dependence with other cannabis-induced disorder

F12.921 Cannabis use, unspecified with intoxication delirium

F12.929 Cannabis use, unspecified with intoxication, unspecified

Data Source: Local Coverage Determination

for Heavy Metal Testing (L35074)

10/01/16

F12.988 Cannabis use, unspecified with other cannabis-induced disorder

F13.121 Sedative, hypnotic or anxiolytic abuse with intoxication delirium

F13.129 Sedative, hypnotic or anxiolytic abuse with intoxication, unspecified

F13.14 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-

induced mood disorder

F13.159 Sedative, hypnotic or anxiolytic abuse with sedative, hypnotic or anxiolytic-

induced psychotic disorder, unspecified

F13.188 Sedative, hypnotic or anxiolytic abuse with other sedative, hypnotic or

anxiolytic-induced disorder

F13.221 Sedative, hypnotic or anxiolytic dependence with intoxication delirium

F13.229 Sedative, hypnotic or anxiolytic dependence with intoxication, unspecified

F13.24 Sedative, hypnotic or anxiolytic dependence with sedative, hypnotic or

anxiolytic-induced mood disorder


anxiolytic-induced psychotic disorder, unspecified


anxiolytic-induced persisting amnestic disorder


anxiolytic-induced persisting dementia

F13.921 Sedative, hypnotic or anxiolytic use, unspecified with intoxication delirium

F13.929 Sedative, hypnotic or anxiolytic use, unspecified with intoxication,

unspecified

F13.94 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic or

anxiolytic-induced mood disorder

http://questnet1.qdx.com/index.hthttp://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=32965&ContrId=180&ver=8&ContrVer=1&CntrctrSelected=180*1&Cntrctr=180&name=National+Government+Services,+Inc.+(13102,+MAC+-+Part+B)&DocType=Active&LCntrctr=54*1|55*1|56*1|52*1|53*1|51*1|57*1|63*1|89*1|64*1|65*1|192*1|1*1|2*1|178*1|180*1|179*1|181*1|182*1|183*1|138*1&bc=AgACAAIAAAAAAA==&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35074&ContrId=299&ver=9&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAQAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35074&ContrId=299&ver=9&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAQAAAAAAA%3d%3d&

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83655, 83785, 83825, 83885, 84255, 84285, 84630













F13.96 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic

or anxiolytic-induced persisting amnestic disorder

F13.97 Sedative, hypnotic or anxiolytic use, unspecified with sedative, hypnotic

or anxiolytic-induced persisting dementia

F13.988 Sedative, hypnotic or anxiolytic use, unspecified with other sedative,

hypnotic or anxiolytic-induced disorder

F14.121 Cocaine abuse with intoxication with delirium

F14.129 Cocaine abuse with intoxication, unspecified

F14.14 Cocaine abuse with cocaine-induced mood disorder

F14.188 Cocaine abuse with other cocaine-induced disorder

F14.221 Cocaine dependence with intoxication delirium

F14.229 Cocaine dependence with intoxication, unspecified

F14.24 Cocaine dependence with cocaine-induced mood disorder

F14.288 Cocaine dependence with other cocaine-induced disorder

F14.921 Cocaine use, unspecified with intoxication delirium

F14.929 Cocaine use, unspecified with intoxication, unspecified

F14.94 Cocaine use, unspecified with cocaine-induced mood disorder

F14.988 Cocaine use, unspecified with other cocaine-induced disorder

F15.121 Other stimulant abuse with intoxication delirium

F15.129 Other stimulant abuse with intoxication, unspecified

F15.14 Other stimulant abuse with stimulant-induced mood disorder

F15.188 Other stimulant abuse with other stimulant-induced disorder

F15.221 Other stimulant dependence with intoxication delirium

F15.229 Other stimulant dependence with intoxication, unspecified

F15.24 Other stimulant dependence with stimulant-induced mood disorder

Data Source: Local Coverage Determination (LCD): Heavy Metal Testing (L35074)

10/01/16

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

http://questnet1.qdx.com/index.hthttp://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=32965&ContrId=180&ver=8&ContrVer=1&CntrctrSelected=180*1&Cntrctr=180&name=National+Government+Services,+Inc.+(13102,+MAC+-+Part+B)&DocType=Active&LCntrctr=54*1|55*1|56*1|52*1|53*1|51*1|57*1|63*1|89*1|64*1|65*1|192*1|1*1|2*1|178*1|180*1|179*1|181*1|182*1|183*1|138*1&bc=AgACAAIAAAAAAA==&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35074&ContrId=299&ver=6&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&DocType=Future&LCntrctr=299*1&bc=AgACAAIAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35074&ContrId=299&ver=9&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAQAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35074&ContrId=299&ver=9&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAQAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35074&ContrId=299&ver=9&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAQAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35074&ContrId=299&ver=9&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAQAAAAAAA%3d%3d&

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83655, 83785, 83825, 83885, 84255, 84285, 84630













F18.27 Inhalant dependence with inhalant-induced dementia

F18.288 Inhalant dependence with other inhalant-induced disorder

F18.921 Inhalant use, unspecified with intoxication with delirium

F18.929 Inhalant use, unspecified with intoxication, unspecified

F18.94 Inhalant use, unspecified with inhalant-induced mood disorder

F18.97 Inhalant use, unspecified with inhalant-induced persisting dementia

F18.988 Inhalant use, unspecified with other inhalant-induced disorder

F19.121 Other psychoactive substance abuse with intoxication delirium

F19.129 Other psychoactive substance abuse with intoxication, unspecified

F19.14 Other psychoactive substance abuse with psychoactive substance-



induced persisting amnestic disorder


induced persisting dementia

F19.188 Other psychoactive substance abuse with other psychoactive substance-

induced disorder

F19.221 Other psychoactive substance dependence with intoxication delirium

F19.229 Other psychoactive substance dependence with intoxication, unspecified

F19.24 Other psychoactive substance dependence with psychoactive

substance- induced mood disorder

F19.26 Other psychoactive substance dependence with psychoactive substance-

induced persisting amnestic disorder

F19.27 Other psychoactive substance dependence with psychoactive substance-



10/01/16

F19.288 Other psychoactive substance dependence with other psychoactive

substance-induced disorder

F19.921 Other psychoactive substance use, unspecified with intoxication with delirium

F19.929 Other psychoactive substance use, unspecified with intoxication, unspecified

F19.94 Other psychoactive substance use, unspecified with psychoactive substance-



Induced persisting amnestic disorder



F19.988 Other psychoactive substance use, unspecified with other psychoactive

substance-induced disorder

N18.1 Chronic kidney disease, stage 1

N18.2 Chronic kidney disease, stage 2 (mild)

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 End stage renal disease

N18.9 Chronic kidney disease, unspecified

T47.0X4A Poisoning by histamine H2-receptor blockers, undetermined, initial

encounter

T47.0X4D Poisoning by histamine H2-receptor blockers, undetermined, subsequent

encounter

T47.0X4S Poisoning by histamine H2-receptor blockers, undetermined, sequela

T47.1X4A Poisoning by other antacids and anti-gastric-secretion drugs,

undetermined, initial encounter

http://questnet1.qdx.com/index.hthttp://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=32965&ContrId=180&ver=8&ContrVer=1&CntrctrSelected=180*1&Cntrctr=180&name=National+Government+Services,+Inc.+(13102,+MAC+-+Part+B)&DocType=Active&LCntrctr=54*1|55*1|56*1|52*1|53*1|51*1|57*1|63*1|89*1|64*1|65*1|192*1|1*1|2*1|178*1|180*1|179*1|181*1|182*1|183*1|138*1&bc=AgACAAIAAAAAAA==&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35074&ContrId=299&ver=9&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAQAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35074&ContrId=299&ver=9&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAQAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35074&ContrId=299&ver=9&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAQAAAAAAA%3d%3d&https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35074&ContrId=299&ver=9&ContrVer=1&CntrctrSelected=299*1&Cntrctr=299&name=National+Government+Services,+Inc.+(National+Government+Services,+Inc.+(13102,+A+and+B+and+HHH+MAC,+J+-+K))&LCntrctr=299*1&DocType=Active&bc=AgACAAQAAAAAAA%3d%3d&

Last Updated:










83655, 83785, 83825, 83885, 84255, 84285, 84630













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


10/01/16

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


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K63.89 Other specified diseases of intestine

K92.89 Other specified diseases of the digestive system

L23.1 Allergic contact dermatitis due to adhesives

L23.5 Allergic contact dermatitis due to other chemical products

L24.5 Irritant contact dermatitis due to other chemical products

L25.3 Unspecified contact dermatitis due to other chemical products

N03.9 Chronic nephritic syndrome with unspecified morphologic changes

R11.2 Nausea with vomiting, unspecified

R19.7 Diarrhea, unspecified

R63.4 Abnormal weight loss

T57.0X4A 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





10/01/16

CPT 83018: Beryllium- Serum and/or urine beryllium testing is payable for

beneficiaries with pulmonary disease with industrial exposure to beryllium.


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





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Heavy Metal Testing (pg . 6 of 10) CPT Codes: 82108, 82175, 82300, 82495, 82525, 83018,

83655, 83785, 83825, 83885, 84255, 84285, 84630













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.


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,


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.


T56.2X4A Toxic effect of chromium and its compounds, undetermined, initial

encounter

T56.2X4D Toxic effect of chromium and its compounds, undetermined,


T56.2X4S Toxic effect of chromium and its compounds, undetermined, sequela


10/01/16

CPT 83018: Cobalt. Serum cobalt testing is payable for beneficiaries with an

industrial exposure to cobalt with evidence of pulmonary disease





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 Wilsons 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


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83655, 83785, 83825, 83885, 84255, 84285, 84630













E83.00 Disorder of copper metabolism, unspecified

E83.09 Other disorders of copper metabolism

I42.9 Cardiomyopathy, unspecified


K73.0 Chronic persistent hepatitis, not elsewhere classified

K73.9 Chronic hepatitis, unspecified

K74.60 Unspecified cirrhosis of liver

K74.69 Other cirrhosis of liver

K76.9 Liver disease, unspecified


Q89.8 Other specified congenital malformations

R63.3 Feeding difficulties

R74.8 Abnormal levels of other serum enzymes

R74.9 Abnormal serum enzyme level, unspecified




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.


10/01/16

G58.8 Other specified mononeuropathies

G58.9 Mononeuropathy, unspecified

G60.0 Hereditary motor and sensory neuropathy

G60.1 Refsum's disease

G60.2 Neuropathy in association with hereditary ataxia

G60.3 Idiopathic progressive neuropathy

G60.8 Other hereditary and idiopathic neuropathies

G60.9 Hereditary and idiopathic neuropathy, unspecified

G93.40 Encephalopathy, unspecified

G93.41 Metabolic encephalopathy

G93.49 Other encephalopathy

R71.0 Precipitous drop in hematocrit

R71.8 Other abnormality of red blood cells

R93.6 Abnormal findings on diagnostic imaging of limbs

R93.7 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


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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

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,


T57.2X4S Toxic effect of manganese and its compounds, undetermined, sequela

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


10/01/16

I69.193 Ataxia following nontraumatic intracerebral hemorrhage

I69.293 Ataxia following other nontraumatic intracranial hemorrhage

I69.393 Ataxia following cerebral infarction

I69.893 Ataxia following other cerebrovascular disease

I69.993 Ataxia following unspecified cerebrovascular disease


R27.0 Ataxia, unspecified

R27.8 Other lack of coordination

R27.9 Unspecified lack of coordination

T37.8X1A Poisoning by other specified systemic anti-infectives and antiparasitics,

accidental (unintentional), initial encounter

T37.8X1D Poisoning by other specified systemic anti-infectives and antiparasitics,

accidental (unintentional), subsequent encounter

T37.8X1S Poisoning by other specified systemic anti-infectives and antiparasitics,

accidental (unintentional), sequela

T47.4X4A Poisoning by other laxatives, undetermined, initial encounter

T47.4X4D Poisoning by other laxatives, undetermined, subsequent encounter

T47.4X4S Poisoning by other laxatives, undetermined, sequela

T49.8X4A Poisoning by other topical agents, undetermined, initial encounter

T49.8X4D Poisoning by other topical agents, undetermined, subsequent encounter

T49.8X4S Poisoning by other topical agents, undetermined, sequela

T56.1X4A Toxic effect of mercury and its compounds, undetermined, initial

encounter

T56.1X4D Toxic effect of mercury and its compounds, undetermined, subsequent

encounter

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Documents

Medicare National and Local Coverage Determination … · Medicare National and Local Coverage Determination Policy- CT, MA, ME, NH, RI, VT 10/01/16