Local Coverage Determination (LCD) for Ambulance Services (Ground Ambulance) 4T-3AB-R7 (L28627)

Transcription

1 Lcal Cverage Determinatin (LCD) fr Ambulance Services (Grund Ambulance) 4T-3AB-R7 (L28627) Cntractr Infrmatin Cntractr Name TrailBlazer Health Enterprises, LLC LCD Infrmatin Dcument Infrmatin LCD ID Number L28627 LCD Title Ambulance Services (Grund Ambulance) 4T-3AB-R7 Oversight Regin Regin IV Cntractr's Determinatin Number 4T-3AB AMA CPT/ADA CDT Cpyright Statement CPT cdes, descriptins and ther data nly are cpyright 2011 American Medical Assciatin (r such ther date f publicatin f CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminlgy, (CDT) (including prcedure cdes, nmenclature, descriptrs and ther data cntained therein) is cpyright by the American Dental Assciatin. 2002, 2004 American Dental Assciatin. All rights reserved. Applicable FARS/DFARS apply. CMS Natinal Cverage Plicy Original Determinatin Effective Date Fr services perfrmed n r after 04/14/2009 Original Determinatin Ending Date Revisin Effective Date Fr services perfrmed n r after 10/01/2011 Revisin Ending Date

2 This LCD supplements but des nt replace, mdify r supersede existing Medicare applicable Natinal Cverage Determinatins (NCDs) r payment plicy rules and regulatins fr nn-emergency grund ambulance services. Federal statute and subsequent Medicare regulatins regarding prvisin and payment fr medical services are lengthy. They are nt repeated in this LCD. Neither Medicare payment plicy rules nr this LCD replace, mdify r supersede applicable state statutes regarding medical practice r ther health practice prfessins acts, definitins and/r scpes f practice. All prviders wh reprt services fr Medicare payment must fully understand and fllw all existing laws, regulatins and rules fr Medicare payment fr nn-emergency grund ambulance services and must prperly submit nly valid claims fr them. Please review and understand them and apply the medical necessity prvisins in the plicy within the cntext f the manual rules. Relevant CMS manual instructins and plicies regarding nn-emergency grund ambulance services are fund in the fllwing Internet- Only Manuals (IOMs) published n the CMS Web site: Medicare Benefit Plicy Manual Pub Medicare Natinal Cverage Determinatins Manual Pub Medicare Prvider Integrity Manual Pub Crrect Cding Initiative Medicare Cntractr Beneficiary and Prvider Cmmunicatins Manual Pub , Chapter 5. Federal Register, Vl. 66, N. 233, December 4, Federal Register, Vl. 67, N. 39, February 27, CFR Scial Security Act (Title XVIII) Standard References, Sectins: 1862 (a)(1)(a) Medically Reasnable & Necessary (e) Incmplete Claim (s)(7)ambulance Service (v)(1)(k)(ii) Bna Fide Emergency Services. Indicatins and Limitatins f Cverage and/r Medical Necessity Ntice: It is nt apprpriate t bill Medicare fr services that are nt cvered (as described by this entire LCD) as if they are cvered. When billing fr nn-cvered services, use the apprpriate mdifier (see Cding Guidelines sectin in the attached article fr instructins). The Medicare payment benefit fr ambulance services is very restricted. Ambulance suppliers must understand the benefit and refrain frm seeking Medicare payment fr services that d nt cnfrm t the limited benefit requirements as stated in regulatin. Physicians and thers wh rder and certify medical necessity f ambulance services must als understand and abide by the limitatins f Medicare cverage f ambulance services. This LCD includes, fr reference nly, prtins f CMS natinal payment plicy as fund in relevant Internet-Only Manual (IOM) sectins and regulatins. This LCD

3 further prvides limited cverage diagnsis t prcedure edit requirements fr ambulance suppliers wh chse t submit ICD-9-CM cdes n their claims. The LCD als cntains utilizatin guidelines fr the purpse f autmated ambulance claim denial by TrailBlazer in its jurisdictins. CMS Natinal Payment Plicy Medicare cvers ambulance services nly if furnished t a beneficiary whse medical cnditin at the time f transprt is such that transprtatin by ther means wuld endanger the patient s health. A patient whse cnditin permits transprt in any type f vehicle ther than an ambulance des nt qualify fr Medicare payment. Medicare payment fr ambulance transprtatin depends n the patient s cnditin at the actual time f the transprt regardless f the patient s diagnsis. T be deemed medically necessary fr payment, the patient must require bth the transprtatin and the level f service prvided. Medicare cvers bth emergency ambulance transprtatin and nn-emergency ambulance transprtatin as fllws: Medical Necessity Ambulance transprtatin is cvered when the patient s cnditin requires the vehicle itself and/r the specialized services f the trained ambulance persnnel. A requirement f cverage is that the needed services f the ambulance persnnel were prvided and clear clinical dcumentatin validates their medical need and their prvisin in the recrd f the service (usually the run sheet). Emergency Ambulance Services Medicare will cver emergency ambulance services when the services are medically necessary, meet the destinatin limits f clsest apprpriate facilities and are prvided by an ambulance service that is licensed by the state. Emergency respnse means respnding immediately at the Basic Life Supprt (BLS) r Advanced Life Supprt 1 (ALS1) level f service t a 911 call r the equivalent. An immediate respnse is ne in which the ambulance supplier begins as quickly as pssible t take the steps necessary t respnd t the call. The patient s cnditin is an emergency that renders the patient unable t g safely t the hspital by ther means. Emergency ambulance services are services prvided after the sudden nset f a medical cnditin. Fr the purpses f this LCD, acute signs and/r symptms f sufficient severity must manifest the emergency medical cnditin such that the absence f immediate medical attentin culd reasnably be expected t result in ne r mre f the fllwing: Place the patient s health in serius jepardy.

4 Cause serius impairment t bdily functins. Cause serius dysfunctin f any bdy rgan r part. Nn-Emergency Ambulance Service Ambulance services are cvered in the absence f an emergency cnditin in either f the tw general categries f circumstances that fllw: The patient being transprted has, at the time f grund transprt, a cnditin such that all ther methds f grund transprtatin (e.g., taxi, private autmbile, wheelchair van r ther vehicle) are cntraindicated. In this circumstance, cntraindicated means that the patient cannt be transprted by any ther means frm the rigin t the destinatin withut endangering the individual s health. Having r having had a serius illness, injury r surgery des nt necessarily justify Medicare payment fr ambulance transprtatin, thus a thrugh assessment and dcumented descriptin f the patient s current state is essential fr cverage. All statements abut the patient s medical cnditin must be validated in the dcumentatin using cntempraneus bjective bservatins and findings. See Table I f medical cnditins belw fr examples f findings required fr cverage f ambulance transprtatin. The patient is befre, during and after transprtatin, bed-cnfined. Fr the purpses f this LCD, bed-cnfined means the patient must meet all f the fllwing three criteria: Unable t get up frm bed withut assistance. Unable t ambulate. Unable t sit in a chair (including a wheelchair). As stated in the bullet abve, statements abut the patient s bed-bund status must be validated in the recrd with cntempraneus bjective bservatins and findings as t the patient s functinal physical and/r mental limitatins that have rendered him bed-bund. Nn-emergency ambulance transprtatin is nt cvered fr patients wh are restricted t bed rest by a physician s instructins but wh d nt meet the abve three criteria. If sme means f transprtatin ther than an ambulance (i.e., private car, wheelchair van, etc.) culd be utilized withut endangering the individual s health, whether such ther transprtatin is actually available, n payment may be made fr ambulance service.

5 Nn-emergency ambulance services may be thse that are scheduled in advance scheduled services being either repetitive r nn-repeating. Nn-emergency ambulance transprtatin is nt cvered if transprtatin is prvided fr the patient wh is transprted t receive a service that culd have been safely and effectively prvided in the pint f rigin (residence, Skilled Nursing Facility (SNF), hspital, etc.). Such transprtatin is nt cvered even if the patient culd nly have gne fr the service by ambulance. Ambulance transprtatin fr services excluded frm SNF cnslidated billing must meet the criteria as reasnable and necessary indicated abve. Ambulance transprts t r frm an Independent Diagnstic Testing Facility (IDTF) are cnsidered paid in the SNF Prspective Payment System (PPS) rate when the beneficiary is in a cvered Part A stay and may nt be paid separately as Part B services. The ambulance transprt is included in the SNF PPS rate if the first r secnd character (rigin r destinatin) f any HCPCS cde ambulance mdifier is D (diagnstic r therapeutic site ther than P r H ), and the ther mdifier (rigin r destinatin) is N (SNF). In this instance, the SNF is respnsible fr the csts f the transprt. The D rigin/destinatin mdifier includes cancer treatment centers, wund care centers, radiatin therapy centers, and all ther diagnstic r therapeutic sites. Destinatin Fr ambulance services t be a cvered benefit, the transprt must be t the nearest institutin with apprpriate facilities fr the treatment f the illness r injury invlved. The term apprpriate facilities means that the institutin is generally equipped t prvide hspital care necessary t manage the illness r injury invlved. It is the institutin, its equipment, its persnnel and its capability t prvide the services necessary t supprt the required medical care that determine whether it has apprpriate facilities. The fact that a mre distant institutin may be better equipped (either subjectively r quantitatively) des nt mean that the clser institutin des nt have apprpriate facilities. In the case f a hspital, it als means that a physician r a physician specialist is available t prvide the necessary care required t treat the patient s cnditin. Hwever, the fact that a particular physician des r des nt have staff privileges in a hspital is nt a cnsideratin in determining whether the hspital has apprpriate facilities. Thus, ambulance service t a mre distant hspital slely t avail a patient f the service f a specific physician r physician specialist des nt make the hspital in which the physician has staff privileges the nearest hspital with apprpriate facilities. Hwever, a legal impediment that bars the patient s admissin wuld preclude that institutin frm having apprpriate facilities. Fr example, if the nearest apprpriate specialty hspital is in anther state and that state s law precludes admissin f nn-residents, that facility is nt an apprpriate facility.

6 An institutin is als nt cnsidered an apprpriate facility if there is n bed available. The carrier, hwever, will presume there are beds available at the lcal institutins unless the claimant furnished evidence that nne f these institutins had a bed available at the time the ambulance service was prvided. In the case f ambulance services t a facility ther than the clsest apprpriate facility, nly thse miles t the clsest facility are eligible fr cverage. Cvered destinatins fr emergency ambulance services include: Hspitals. Physician s ffice nly if during an emergency transprtatin t a hspital the ambulance stps at a physician s ffice en rute due t a dire need fr prfessinal attentin and thereafter cntinues t the hspital. In such cases, the patient is deemed nt t have been transprted t the physician s ffice and payment may be made fr the entire trip. Cvered destinatins fr nn-emergency transprts include: Hspitals ( apprpriate facility ). Skilled nursing facilities. Dialysis facilities Ambulance services furnished t a maintenance dialysis patient nly when the patient s cnditin at the time f transprt requires ambulance services. Frm an SNF t the nearest supplier f medically necessary services nt available at the SNF where the beneficiary is a resident, including the return trip (fr instance, cardiac catheterizatin; specialized diagnstic imaging prcedures such as cmputerized axial tmgraphy r magnetic resnance imaging; surgery perfrmed in an perating rm; specialized wund care; cancer treatments) when the patient s cnditin at the time f transprt requires ambulance services. The patient s residence nly if the transprt is t return frm an apprpriate facility and the patient s cnditin at the time f transprt requires ambulance services. Physician Certificatin Statement (PCS) Fr scheduled and nn-scheduled nn-emergency ambulance transprts,

7 prviders f ambulance transprtatin must btain a written statement (PCS) frm the patient s attending physician certifying that medical necessity requirements fr ambulance transprtatin are met. The signature f the medical prfessinal cmpleting the PCS must be legible (r accmpanied by a typed r printed name) and include credentials. Furthermre, signatures n the PCS must be dated at the time they are cmpleted. A PCS is nt required fr emergency transprts r fr nn-scheduled nn-emergency transprts f patients residing at hme r in facilities where they are nt under the direct care f a physician. It is imprtant t nte that the mere presence f the signed physician certificatin statement des nt, by itself, demnstrate that the transprt was medically necessary and des nt abslve the ambulance prvider frm meeting all ther cverage and dcumentatin criteria. Fr nn-repetitive nn-emergency transprts, the fllwing apply: The PCS must be btained frm the attending physician within 48 hurs after the transprt. If the ambulance prvider is unable t btain the PCS frm the attending physician within 48 hurs f transprt, the prvider may submit a claim if a certificatin has been btained frm a Physician Assistant (PA), Nurse Practitiner (NP), Clinical Nurse Specialist (CNS), Registered Nurse (RN) r discharge planner wh is knwledgeable abut the patient s cnditin and wh is emplyed by either the attending physician r the facility in which the patient is admitted. Alternatively, the prvider may submit the claim after 21 days if there is dcumentatin f a gd faith effrt t btain the rder and certificatin. The ambulance supplier must dcument effrts t btain certificatin. When the PCS cannt be btained in accrdance with 42 CFR , the prvider/supplier may send a letter via U.S. Pstal Service certified mail with return receipt and/r prf f mailing r ther similar service demnstrating delivery f the letter as evidence f the attempt t btain the PCS. Fr repetitive nn-emergency transprts, the fllwing apply: A PCS fr repetitive transprts must be signed by the patient s attending physician. The PCS must be dated n earlier than 60 days in advance f the transprt fr thse patients wh require repetitive ambulance services and whse transprtatin is scheduled in advance.

8 Tables f Medical Cnditins The attached tables illustrate Medicare s expectatins with respect t the severity f the patient s cnditin t justify payment fr ambulance transprtatin services when all ther cverage and payment cnditins are met. Thugh nt allinclusive, the fllwing table lists medical cnditins fr which ambulance transprtatin is cmmnly required and can be used t judge relative severity f cnditins nt listed. Medicare requires the run reprt t include a descriptin f the patient s symptms and physical findings in sufficient detail as t demnstrate cnditins such as thse described in the tables. Special Nte Regarding Patients Transprted t and Frm Hemdialysis Centers: Only a fractin (apprximately 10 percent) ESRD patients n chrnic hemdialysis requires ambulance transprtatin t and frm hemdialysis sessins. The presence f ESRD and the requirement fr hemdialysis d nt alne qualify a patient fr ambulance transprtatin. Medicare payment requires patients transprted t and frm hemdialysis centers t have ther cnditins such as thse described in the tables belw and requires adequate dcumentatin f thse cnditins in the ambulance supplier s run reprts and in the medical recrds f ther prviders invlved with the patient s care. See 4T-3AB Table f Cnditins.htm attachment fr medical cnditins. Special Cnsideratins Regarding Beneficiary Death Payment fr ambulance services in circumstances in which the beneficiary dies is based n the time f the beneficiary s death related t the time f the call fr service and transprt. In cases where the beneficiary is prnunced dead after the ambulance is called but befre the ambulance arrives at the scene, payment may be made fr a BLS service. Neither mileage nr a rural adjustment wuld be paid. The blended rate amunt will therwise apply. In cases where the beneficiary is prnunced dead after being laded int the ambulance (regardless f whether the prnuncement is made during r subsequent t the transprt), payment is made fllwing the usual rules f payment as if the beneficiary had nt died. This scenari includes a determinatin f Dead n Arrival (DOA) at the facility t which the beneficiary was transprted. Limitatins

9 Medicare des nt cver the fllwing services: Transprtatin in Ambi-buses, ambulettes (Mbility Assistance Vehicle (MAV)), Medi-cabs, vans, privately wned vehicles, taxicabs. Transprtatin via Mbile Intensive Care Unit (MICU) (if billed under Medicare Part A). Parking fees. Tlls fr bridges, tunnels and highways. Medicare des nt prvide payment fr Ambulance respnse and treatment, n transprt (A0998). Ntice: This LCD impses diagnsis limitatins that supprt diagnsis t prcedure cde autmated denials. Hwever, services perfrmed fr any given diagnsis must meet all f the indicatins and limitatins stated in this plicy, the general requirements fr medical necessity as stated in CMS payment plicy manuals, any and all existing CMS natinal cverage determinatins, and all Medicare payment rules. As published in CMS IOM , Sectin , in rder t be cvered under Medicare, a service shall be reasnable and necessary. When apprpriate, cntractrs shall describe the circumstances under which the prpsed LCD fr the service is cnsidered reasnable and necessary under Sectin 1862(a)(1)(A). Cntractrs shall cnsider a service t be reasnable and necessary if the cntractr determines that the service is: Safe and effective. Nt experimental r investigatinal (exceptin: rutine csts f qualifying clinical trial services with dates f service n r after September 19, 2000, that meet the requirements f the Clinical Trials NCD are cnsidered reasnable and necessary). Apprpriate, including the duratin and frequency that is cnsidered apprpriate fr the service, in terms f whether it is: Furnished in accrdance with accepted standards f medical practice fr the diagnsis r treatment f the patient's cnditin r t imprve the functin f a malfrmed bdy member.

10 Furnished in a setting apprpriate t the patient's medical needs and cnditin. Ordered and furnished by qualified persnnel. One that meets, but des nt exceed, the patient's medical needs. At least as beneficial as an existing and available medically apprpriate alternative. Back t Tp Cding Infrmatin Bill Type Cdes: Cntractrs may specify Bill Types t help prviders identify thse Bill Types typically used t reprt this service. Absence f a Bill Type des nt guarantee that the plicy des nt apply t that Bill Type. Cmplete absence f all Bill Types indicates that cverage is nt influenced by Bill Type and the plicy shuld be assumed t apply equally t all claims. 012x Hspital Inpatient (Medicare Part B nly) 013x Hspital Outpatient 022x Skilled Nursing - Inpatient (Medicare Part B nly) 023x Skilled Nursing - Outpatient 083x Ambulatry Surgery Center 085x Critical Access Hspital Revenue Cdes: Cntractrs may specify Revenue Cdes t help prviders identify thse Revenue Cdes typically used t reprt this service. In mst instances Revenue Cdes are purely advisry; unless specified in the plicy services reprted under ther Revenue Cdes are equally subject t this cverage determinatin. Cmplete absence f all Revenue Cdes indicates that cverage is nt influenced by Revenue Cde and the plicy shuld be assumed t apply equally t all Revenue Cdes. Nte: TrailBlazer has identified the Bill Type and Revenue Cdes applicable fr use with the CPT/HCPCS cdes included in this LCD. Prviders are reminded that nt all CPT/HCPCS cdes listed can be billed with all Bill Type and/r Revenue Cdes listed.

11 CPT/HCPCS cdes are required t be billed with specific Bill Type and Revenue Cdes. Prviders are encuraged t refer t the CMS Internet-Only Manual (IOM), Publicatin , Claims Prcessing Manual, fr further guidance. 054X Ambulance - General Classificatin CPT/HCPCS Cdes Nte: Prviders are reminded t refer t the lng descriptrs f the CPT cdes in their CPT bk. The American Medical Assciatin (AMA) and the Centers fr Medicare & Medicaid Services (CMS) require the use f shrt CPT descriptrs in plicies published n the Web. A0425 Grund mileage A0426 Als 1 A0427 ALS1-emergency A0428 bls A0429 BLS-emergency A0433 als 2 A0434 Specialty care transprt A0888 Nncvered ambulance mileage A0999 Unlisted ambulance service ICD-9 Cdes that Supprt Medical Necessity Nte: Prviders shuld cntinue t submit ICD-9-CM diagnsis cdes withut decimals n their claim frms and electrnic claims. Medical necessity and cverage f ambulance services are nt based slely n the presence f a specific diagnsis. Medicare payment fr ambulance transprtatin may be made nly fr thse patients whse cnditin at the time f transprt is such that ambulance transprtatin is necessary. Fr example, it is insufficient that a patient merely has a diagnsis such as pneumnia, strke r fracture t justify ambulance transprtatin. In each f thse instances, the cnditin f the patient must be such that transprtatin by any ther means is medically cntraindicated. In the case f ambulance transprtatin, the cnditin necessitating transprtatin is ften that an accident r injury has ccurred giving rise t a clinical suspicin that a specific cnditin exists (fr instance, fractures may be strngly suspected based n clinical examinatin and histry f a specific injury). It is the prvider s respnsibility t supply the cntractr with infrmatin describing the cnditin f the patient that necessitated ambulance transprtatin. Medicare recgnizes limitatins f usual ambulance persnnel fr establishing a diagnsis and recgnizes, therefre, that diagnsis cding f a patient s cnditin using ICD-9-CM cdes when reprting ambulance services may be less specific than fr services reprted by ther

12 prfessinal prviders. Als, selected ICD-9-CM diagnsis cdes frm the CMS cnditin cde list are included with instructins t use them in a manner that is cntrary t usual ICD-9-CM cding cnventins. Prviders wh submit ICD-9-CM diagnsis cdes shuld chse the cde that best describes the patient s cnditin at the time f transprt. As a reminder t prviders f ambulance services, rule ut r suspected diagnses shuld nt be reprted using specific ICD-9-CM cdes. In such instances where a diagnsis is nt cnfirmed, it is mre crrect t use a symptm, finding r injury cde. Reprting ambulance services using a cde frm the list belw certifies t Medicare that the ambulance prvider believes the cde descriptin reasnably reflects the cnditin f the patient at the time f transprt and that the patient s cnditin was cnsistent with the requirements f the Medicare ambulance transprtatin benefit. TrailBlazer recgnizes that ambulance suppliers are currently nt required t submit ICD-9-CM cdes n their claims if filing n a 1500 claim frm r utilizing an electrnic versin ther than the 5010 versin f the 837P, thugh their ding s facilitates timely claim adjudicatin. The CPT/HCPCS cdes included in this LCD will be subjected t prcedure t diagnsis editing. The fllwing lists include nly thse diagnses fr which the identified CPT/HCPCS prcedures are cvered. If a claim cntains ne r mre ICD-9-CM diagnses but a cvered diagnsis cde is nt n the claim, the edit will autmatically deny the service as nt medically necessary. Claims withut an ICD-9-CM diagnsis cde are adjudicated manually utilizing the infrmatin cntained in the claim s narrative field and/r medical recrds (the trip reprt and any ther recrds supplied t Medicare by the prvider upn ur request). Ambulance suppliers utilizing the 5010 versin f the 837P are required t submit ICD-9-CM diagnsis cde(s). Medicare is establishing the fllwing limited cverage fr HCPCS cdes A0425, A0426, A0427, A0428, A0429, A0433 and A0434: Table 1 Cvered fr Ambulance Transprtatin Services t the Site f Medical Care: 041.9* BACTERIAL INFECTION UNSPECIFIED IN CONDITIONS CLASSIFIED ELSEWHERE AND OF UNSPECIFIED SITE MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE - MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANT ORGAN DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH KETOACIDOSIS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH KETOACIDOSIS, TYPE I [JUVENILE TYPE], UNCONTROLLED

13 DIABETES WITH HYPEROSMOLARITY, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH HYPEROSMOLARITY, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH OTHER COMA, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH OTHER COMA, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH RENAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH RENAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH OPHTHALMIC MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH NEUROLOGICAL MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED - DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED - DIABETES WITH OTHER SPECIFIED MANIFESTATIONS, TYPE I [JUVENILE TYPE], UNCONTROLLED HYPOGLYCEMIC COMA - OTHER SPECIFIED HYPOGLYCEMIA VOLUME DEPLETION, UNSPECIFIED - HYPOVOLEMIA ALCOHOL WITHDRAWAL DELIRIUM ALCOHOL WITHDRAWAL DRUG WITHDRAWAL PATHOLOGICAL DRUG INTOXICATION 293.0* DELIRIUM DUE TO CONDITIONS CLASSIFIED ELSEWHERE 293.1* SUBACUTE DELIRIUM 298.8* OTHER AND UNSPECIFIED REACTIVE PSYCHOSIS NONDEPENDENT ALCOHOL ABUSE UNSPECIFIED DRINKING BEHAVIOR - NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE EPISODIC USE * OTHER DISORDERS OF IMPULSE CONTROL ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF ANTEROLATERAL WALL SUBSEQUENT EPISODE OF CARE

14 ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER ANTERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROLATERAL WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF INFEROPOSTERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER INFERIOR WALL SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER LATERAL WALL SUBSEQUENT EPISODE OF CARE TRUE POSTERIOR WALL INFARCTION EPISODE OF CARE UNSPECIFIED - TRUE POSTERIOR WALL INFARCTION SUBSEQUENT EPISODE OF CARE SUBENDOCARDIAL INFARCTION EPISODE OF CARE UNSPECIFIED - SUBENDOCARDIAL INFARCTION SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF OTHER SPECIFIED SITES SUBSEQUENT EPISODE OF CARE ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE EPISODE OF CARE UNSPECIFIED - ACUTE MYOCARDIAL INFARCTION OF UNSPECIFIED SITE SUBSEQUENT EPISODE OF CARE PRINZMETAL ANGINA IATROGENIC PULMONARY EMBOLISM AND INFARCTION SADDLE EMBOLUS OF PULMONARY ARTERY OTHER PULMONARY EMBOLISM AND INFARCTION CARDIAC TAMPONADE ATRIOVENTRICULAR BLOCK COMPLETE OTHER LEFT BUNDLE BRANCH BLOCK RIGHT BUNDLE BRANCH BLOCK RIGHT BUNDLE BRANCH BLOCK AND LEFT POSTERIOR FASCICULAR BLOCK - TRIFASCICULAR BLOCK PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA - PAROXYSMAL VENTRICULAR TACHYCARDIA

15 ATRIAL FIBRILLATION - ATRIAL FLUTTER VENTRICULAR FIBRILLATION - VENTRICULAR FLUTTER CARDIAC ARREST OTHER PREMATURE BEATS SINOATRIAL NODE DYSFUNCTION CONGESTIVE HEART FAILURE UNSPECIFIED - LEFT HEART FAILURE UNSPECIFIED SYSTOLIC HEART FAILURE - ACUTE ON CHRONIC SYSTOLIC HEART FAILURE UNSPECIFIED DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC DIASTOLIC HEART FAILURE UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE - ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE 428.9* HEART FAILURE UNSPECIFIED 431 INTRACEREBRAL HEMORRHAGE CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT CEREBRAL INFARCTION - CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA 436 ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE COGNITIVE DEFICITS HEMIPLEGIA AFFECTING UNSPECIFIED SIDE - HEMIPLEGIA AFFECTING NONDOMINANT SIDE MONOPLEGIA OF LOWER LIMB AFFECTING UNSPECIFIED SIDE MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) PHLEBITIS AND THROMBOPHLEBITIS OF OTHER HYPOTENSION UNSPECIFIED HEMORRHAGE UNSPECIFIED ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION 496* CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED 514 PULMONARY CONGESTION AND HYPOSTASIS ACUTE EDEMA OF LUNG UNSPECIFIED TRANSFUSION RELATED ACUTE LUNG INJURY (TRALI)

16 530.3 STRICTURE AND STENOSIS OF ESOPHAGUS INTESTINAL OR PERITONEAL ADHESIONS WITH OBSTRUCTION (POSTOPERATIVE) (POSTINFECTION) OTHER SPECIFIED INTESTINAL OBSTRUCTION HEMORRHAGE OF GASTROINTESTINAL TRACT UNSPECIFIED OTHER SPECIFIED COMPLICATIONS OF PREGNANCY UNSPECIFIED AS TO EPISODE OF CARE PRESSURE ULCER, LOWER BACK - PRESSURE ULCER, BUTTOCK PRESSURE ULCER, STAGE III - PRESSURE ULCER, STAGE IV CONTRACTURE OF JOINT SITE UNSPECIFIED - CONTRACTURE OF JOINT OF MULTIPLE SITES * PAIN IN JOINT INVOLVING MULTIPLE SITES PAIN IN THORACIC SPINE LUMBAGO BACKACHE UNSPECIFIED SWELLING OF LIMB COMA - PERSISTENT VEGETATIVE STATE ALTERATION OF CONSCIOUSNESS OTHER HALLUCINATIONS - SYNCOPE AND COLLAPSE COMPLEX FEBRILE CONVULSIONS POST TRAUMATIC SEIZURES OTHER CONVULSIONS FEVER, UNSPECIFIED - POSTPROCEDURAL FEVER * * HYPOTHERMIA NOT ASSOCIATED WITH LOW ENVIRONMENTAL TEMPERATURE FUNCTIONAL QUADRIPLEGIA ALTERED MENTAL STATUS * ABNORMALITY OF GAIT - TRANSIENT PARALYSIS OF LIMB MENINGISMUS CYANOSIS HEADACHE APHASIA TACHYCARDIA UNSPECIFIED - PALPITATIONS GANGRENE SHOCK UNSPECIFIED - SEPTIC SHOCK

17 OTHER SHOCK WITHOUT TRAUMA * RESPIRATORY ABNORMALITY OTHER UNSPECIFIED CHEST PAIN - PAINFUL RESPIRATION NAUSEA WITH VOMITING VOMITING ALONE ABDOMINAL PAIN RIGHT UPPER QUADRANT - ABDOMINAL PAIN GENERALIZED ABDOMINAL PAIN OTHER SPECIFIED SITE ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED SITE - ABDOMINAL OR PELVIC SWELLING MASS OR LUMP GENERALIZED ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED SITE ABDOMINAL RIGIDITY UNSPECIFIED SITE - ABDOMINAL RIGIDITY GENERALIZED ABDOMINAL RIGIDITY OTHER SPECIFIED SITE ABDOMINAL TENDERNESS UNSPECIFIED SITE - ABDOMINAL TENDERNESS GENERALIZED ABDOMINAL TENDERNESS OTHER SPECIFIED SITE ELEVATED BLOOD PRESSURE READING WITHOUT DIAGNOSIS OF HYPERTENSION ASPHYXIA - HYPOXEMIA RESPIRATORY ARREST APPARENT LIFE THREATENING EVENT IN INFANT OTHER CLOSED SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER CLOSED SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER CLOSED SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED

18 DURATION OTHER CLOSED SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF UNCONSCIOUSNESS UNSPECIFIED - OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER CLOSED SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER CLOSED SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER SITE OF CLOSED SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER SITE OF CLOSED SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITHOUT INJURY WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITHOUT INTRACRANIAL INJURY WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH CEREBRAL LACERATION AND CONTUSION WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH SUBARACHNOID SUBDURAL AND EXTRADURAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH STATE OF CONSCIOUSNESS

19 UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH OTHER AND UNSPECIFIED INTRACRANIAL HEMORRHAGE WITH CONCUSSION UNSPECIFIED OTHER OPEN SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH STATE OF CONSCIOUSNESS UNSPECIFIED - OTHER OPEN SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION OTHER OPEN SKULL FRACTURE WITH INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH CONCUSSION UNSPECIFIED CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - CLOSED FRACTURE OF MULTIPLE CERVICAL VERTEBRAE OPEN FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - OPEN FRACTURE OF MULTIPLE CERVICAL VERTEBRAE CLOSED FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED PART OF VERTEBRAL COLUMN WITHOUT SPINAL CORD INJURY CLOSED FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF C1-C4 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF C5-C7 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY OPEN FRACTURE OF T1-T6 LEVEL WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF T7-T12 LEVEL WITH OTHER SPECIFIED SPINAL CORD INJURY CLOSED FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY - OPEN FRACTURE OF LUMBAR SPINE WITH SPINAL CORD INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY CLOSED FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY OPEN FRACTURE OF SACRUM AND COCCYX WITH UNSPECIFIED SPINAL CORD INJURY - OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER CAUDA EQUINA INJURY OPEN FRACTURE OF SACRUM AND COCCYX WITH OTHER SPINAL CORD INJURY

20 CLOSED FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY - OPEN FRACTURE OF UNSPECIFIED VERTEBRA WITH SPINAL CORD INJURY CLOSED FRACTURE OF ACETABULUM - OPEN FRACTURE OF PUBIS CLOSED FRACTURE OF ILIUM - MULTIPLE CLOSED PELVIC FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE CLOSED FRACTURE OF OTHER SPECIFIED PART OF PELVIS OPEN FRACTURE OF ILIUM - MULTIPLE OPEN PELVIC FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE OPEN FRACTURE OF OTHER SPECIFIED PART OF PELVIS UNSPECIFIED CLOSED FRACTURE OF PELVIS - UNSPECIFIED OPEN FRACTURE OF PELVIS OPEN FRACTURE OF CLAVICLE UNSPECIFIED PART - OPEN FRACTURE OF ACROMIAL END OF CLAVICLE FRACTURE OF UNSPECIFIED PART OF UPPER END OF HUMERUS OPEN - FRACTURE OF GREATER TUBEROSITY OF HUMERUS OPEN OTHER OPEN FRACTURE OF UPPER END OF HUMERUS FRACTURE OF UNSPECIFIED PART OF HUMERUS CLOSED FRACTURE OF SHAFT OF HUMERUS CLOSED FRACTURE OF UNSPECIFIED PART OF HUMERUS OPEN - FRACTURE OF SHAFT OF HUMERUS OPEN FRACTURE OF UNSPECIFIED PART OF LOWER END OF HUMERUS OPEN - FRACTURE OF UNSPECIFIED CONDYLE(S) OF HUMERUS OPEN OTHER FRACTURE OF LOWER END OF HUMERUS OPEN ILL-DEFINED OPEN FRACTURES OF UPPER LIMB MULTIPLE CLOSED FRACTURES INVOLVING BOTH UPPER LIMBS AND UPPER LIMB WITH RIB(S) AND STERNUM - MULTIPLE OPEN FRACTURES INVOLVING BOTH UPPER LIMBS AND UPPER LIMB WITH RIB(S) AND STERNUM FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR CLOSED - FRACTURE OF BASE OF NECK OF FEMUR CLOSED OTHER TRANSCERVICAL FRACTURE OF FEMUR CLOSED FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR OPEN - FRACTURE OF BASE OF NECK OF FEMUR OPEN OTHER TRANSCERVICAL FRACTURE OF FEMUR OPEN FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR CLOSED - FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR CLOSED FRACTURE OF UNSPECIFIED TROCHANTERIC SECTION OF FEMUR OPEN - FRACTURE OF SUBTROCHANTERIC SECTION OF FEMUR OPEN