NCD for Lipids Testing

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1 Applicable CPT Code(s): NCD for Lipids Testing Lipid panel Cholesterol, serum or whole blood, total Lipoprotein, blood; electrophoretic separation and quantitation Lipoprotein blood; high resolution fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (e.g., electrophoresis, ultracentrifugation) Lipoprotein, blood; quantitation of lipoprotein particle numbers and lipoprotein particle subclasses Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Lipoprotein, direct measurement, LDL cholesterol Triglycerides ICD-9 Codes that Support Medical Necessity: Code Description Light for dates with signs of fetal malnutrition Abnormal alkaline phosphatase Abnormal transaminase Acute kidney failure with lesion of tubular necrosis Acute myocardial infarction Alcoholism Amyloidosis, unspecified Aneurysm of heart (wall) Angina pectoris Aortic aneurysms and dissection Arterial embolism & thrombosis Atherosclerosis of aorta; of other arteries; of bypass grafts Atherosclerosis of other specified arteries; generalized and unspecified atherosclerosis Biliary atresia Cerebral atherosclerosis Chest pain unspecified Chest pain, other Chronic ischemic heart disease, unspecified Chronic kidney disease

2 440.4 Chronic total occlusion of the artery of the extremities Chronic vascular insufficiency of intestine Complication of transplanted organ, kidney Coronary atherosclerosis Coronary atherosclerosis due to lipid rich plaque Coronary atherosclerosis, of artery bypass graft Coronary atherosclerosis, of bypass graft (artery) (vein) of transplanted heart Coronary atherosclerosis, of coronary artery of transplanted heart Coronary atherosclerosis, of unspecified graft Coronary occlusion without myocardial infarction Coronary vessel aneurysm Crystalline deposits in vitreous Cushing s syndrome Degenerative & vascular disorder of ear, unspecified Diabetes mellitus Disorders of the thyroid gland with hormonal dysfunction Dissection of coronary artery Disturbances of amino-acid transport 401.0, 401.1, Essential hypertension Familial Mediterranean fever Galactosemia Heart disease NOS Heart disease, unspecified Heart failure Hepatomegaly Hyperchylomicronemia Hypertensive chronic kidney disease Hypertensive heart and chronic kidney disease Hypertensive heart disease Hypertriglyceridemia Iliac artery aneurysm Impotence of organic origin, penis disorder 431 Intracerebral hemorrhage 260 Kwashiorkor 438.0, Late effects of cerebrovascular disease , , ,

3 , , , 438.6, 438.7, , , Lipidoses Lipodystrophy Lipoprotein deficiencies Liver disorder antepartum Liver disorders in pregnancy V58.69 Long term (current) use of other medications V58.63-V58.64 Long-term (current) drug use Malnutrition of mild degree Malnutrition of moderate degree Mixed hyperlipidemia (tuberous xanthoma) Morbid obesity Moyamoya disease Nephrogenic diabetes insipidus Nephrotic syndrome Nonspecific (abnormal) findings on radiological and other examination of gastrointestinal tract 261 Nutritional marasmus Obesity Occlusion & stenosis of precerebral arteries Occlusion of cerebral arteries 412 Old myocardial infarction V42.7 Organ replacement by transplant, liver Other & unspecified postsurgical nonabsorption Other abnormal blood chemistry Other acute & subacute forms of ischemic heart disease Other acute and subacute ischemic heart disease Other amyloidosis Other and unspecified angina pectoris Other and unspecified hyperlipidemia (unspecified xanthoma) Other aneurysm of heart Other background retinopathy and retinal vascular change Other chronic non-alcoholic liver disease Other disorders of lipoid metabolism Other generalized ischemic cerebrovascular

4 disease Other protein-calorie malnutrition Other psoriasis 262 Other severe, protein-calorie malnutrition Other specified disorders of liver Other specified disorders resulting from impaired renal function Other specified forms of chronic ischemic heart disease Other specified intestinal malabsorption Overweight Pancreatic disease Precordial pain Psoriatic arthropathy Pure hypercholesterolemia Renal artery aneurysm Renal osteodystrophy Retinal exudates and deposits Retinal vascular occlusion Secondary diabetes mellitus with hyperosmolarity Secondary diabetes mellitus with ketoacidosis Secondary diabetes mellitus with neurological Secondary diabetes mellitus with ophthalmic Secondary diabetes mellitus with other coma Secondary diabetes mellitus with other specified Secondary diabetes mellitus with peripheral circulatory disorders Secondary diabetes mellitus with renal Secondary diabetes mellitus with unspecified complication Secondary diabetes mellitus without mention of complication Secondary hyperparathyroidism (of renal origin) Secondary hypertension Senile corneal changes V81.0-V81.2 Covered only for procedure codes 80061, 82465, Special screening for cardiovascular, respiratory, and genitourinary diseases

5 83718 & Thyroid dysfunction in pregnancy and the puerperium Toxic effect of unspecified gas or vapor Transient cerebral ischemia Transient ischemic deafness V42.0 Transplanted organ, kidney Unspecified chronic liver disease without mention of alcohol Unspecified disorder resulting from impaired renal function Unspecified disorders of lipoid metabolism Unspecified disorders of liver Unspecified protein-calorie malnutrition Upper extremity aneurysm Xanthelasma

LIPID PANEL CHOLESTEROL LIPOPROTEIN, ELECTROPHORETIC SEPARATION LIPOPROTEIN, DIRECT MEASUREMENT (HDL) LDL DIRECT TRIGLYCERIDES

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