Medicare Limited Coverage Tests
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1 Glucose Testing (Blood) National Coverage Determination CPT Codes: Glucose; quantitative, blood (except reagent strips) Glucose; blood, reagent strips Glucose; blood by glucose monitoring device(s) cleared by the FDA specifically for home use Numerical Sort: Pulmonary tuberculosis Septicemia Recurrent vaginal candidiasis Interdigital candidiasis 118 Opportunistic mycoses Malignant neoplasm of Islets of Langerhans Malignant neoplasm of retroperitoneum Benign neoplasm of Islets of Langerhans Thyrotoxicosis with or without goiter Diabetes, secondary Diabetes mellitus Other disorders of pancreatic internal secretion Disorders of the pituitary gland and its hypothalamic control Cushing s syndrome Other and unspecified protein-calorie malnutrition Disorders of carbohydrate transport and metabolism Disorders of lipoid metabolism Disorders of iron metabolism Disorders of fluid, electrolyte, and acid-base balance Hypercarotinemia Delirium due to conditions classified elsewhere Unspecified persistent mental disorders due to conditions classified elsewhere Unspecified psychosis Unspecified nonpsychotic mental disorders Personality change due to conditions classified elsewhere Mild cognitive impairment, so stated Unspecified disorder of autonomic nervous system Generalized convulsive epilepsy Encephalopathy, metabolic Mononeuritis of unspecified site Hereditary and idiopathic peripheral neuropathy; unspecified Inflammatory and toxin neuropathy; unspecified Background retinopathy, unspecified Retinal vasculitis Other nondiabetic proliferative retinopathy Degeneration of macula and posterior pole Peripheral retinal degenerations Other retinal disorders Unspecified retinal disorders Ocular hypertension Corticosteroid-induced glaucoma residual Infantile, juvenile, and presenile cataract Senile cataract Myopia Other specified visual disturbances Blepharitis, unspecified Pseudopapilledema Unspecified disorder of optic nerve and visual pathways Paralytic strabismus January 2015 Medicare Limited Coverage Tests
2 Argyll Robertson pupil, atypical Acute myocardial infarction Other forms of chronic ischemic heart disease Atherosclerosis; coronary, due to lipid rich plaque Atherosclerosis, coronary, due to calcified coronary lesion Secondary cardiomyopathy, unspecified Atherosclerosis of the extremities with ulceration Atherosclerosis of the extremities with gangrene Generalized and unspecified atherosclerosis Orthostatic hypotension 462 Acute pharyngitis Acute bronchitis Pneumonia and influenza 490 Bronchitis, not specified as acute or chronic Chronic bronchitis Disturbance of salivary secretion Stomatitis and mucositis, unspecified Stomatitis and mucositis (ulcerative), other Unspecified gastritis and gastroduodenitits Dyspepsia and other specified disorders of function of stomach Other chronic nonalcoholic liver disease Liver abscess and sequelae of chronic liver disease Calculus of bile duct without mention of cholecystitis Other disorders of gallbladder Cholangitis Acute pancreatitis Chronic pancreatitis Other specified diseases of pancreas Infections of kidney Cystitis, unspecified Atony of bladder Paralysis of bladder Urinary tract infection, site not specified Impotence of organic origin Other specified disorders of male genital organs; other Vaginitis and vulvoaginitis, unspecified Absence of menstruation Irregular menstrual cycle Infertility, female, of unspecified origin Diabetes mellitus complicating pregnancy, childbirth or the puerperium; unspecified as to episode of care or not applicable Diabetes mellitus complicating pregnancy, childbirth or the puerperium; antepartum Diabetes mellitus complicating pregnancy, childbirth or the puerperium; postpartum Abnormal glucose tolerance complicating pregnancy, childbirth or the puerperium; unspecified as to episode of care or not applicable Abnormal glucose tolerance complicating pregnancy, childbirth or the puerperium; antepartum Abnormal glucose tolerance complicating pregnancy, childbirth or the puerperium; postpartum Bariatric surgery status complicating pregnancy, childbirth, or the puerperium Excessive fetal growth Polyhydramnios Carbuncle and furuncle Other local infections of skin and subcutaneous tissue Pruritus ani Pruritus of genital organs Hirsutism Anhidrosis Medicare Limited Coverage Tests January 2015
3 Chronic ulcer of skin Degenerative skin disorders Myalgia and myositis, unspecified Acute osteomyelitis of ankle and foot Chronic osteomyelitis of ankle and foot Unspecified osteomyelitis of ankle and foot Coma Transient alteration of awareness Alteration of consciousness; other Syncope and collapse Convulsions, febrile, unspecified, complex, other Dizziness and giddiness Malaise and fatigue, functional quadriplegia, other malaise and fatigue Generalized hyperhidrosis Abnormal involuntary movements Disturbance of skin sensation Abnormal weight gain Abnormal loss of weight Polydipsia Polyphagia Tachycardia, unspecified Gangrene Hyperventilation Dyspnea and respiratory abnormalities; other Chest pain, unspecified Incontinence of feces Diarrhea Frequency of urination and polyuria Hepatomegaly Abnormal glucose tolerance test (oral) Other abnormal blood chemistry Proteinuria Glycosuria Abnormal reflex Cachexia V23.0-V23.9 Supervision of high-risk pregnancy V58.63-V58.65 Long-term (current) drug use, antiplatelets, non-steroidal anti-inflammatories, steroids V58.67 Long-term (current) use of Insulin V58.69 Long-term (current) use of other medications V67.2 Following chemotherapy V67.51 Following completed treatment with high-risk medications, not elsewhere classified V77.1 Special Screening for endocrine, nutrition, metabolic & immunity disorders (Covered for procedure code only) Medicare Limited Coverage Tests Covered Diagnosis Codes Source: National Coverage Determinations January 2013 Coding Policy Manual and Change Report January 2015 Medicare Limited Coverage Tests
4 Glucose Testing (Blood), Continued Alphabetical Sort: Abnormal glucose tolerance complicating pregnancy, childbirth or the puerperium; postpartum Abnormal glucose tolerance complicating pregnancy, childbirth or the puerperium; antepartum Abnormal glucose tolerance complicating pregnancy, childbirth or the puerperium; unspecified as to episode of care or not applicable Abnormal; glucose tolerance test Abnormal; involuntary movements Abnormal; loss of weight Abnormal; other abnormal blood chemistry Abnormal; reflex Abnormal; weight gain Abscess; liver abscess and sequelae of chronic liver disease Absence of menstruation Alteration; transient alteration of awareness Alteration of consciousness; other Anhidrosis Argyll Robertson pupil, atypical Arteriosclerois; atherosclerosis of the extremities with gangrene Arteriosclerois; atherosclerosis of the extremities with ulceration Atherosclerosis, coronary, due to calcified coronary lesion Atherosclerosis; coronary, due to lipid rich plaque Arteriosclerois; generalized and unspecified atherosclerosis Atony of bladder Bariatric surgery status complicating pregnancy, childbirth, or the puerperium Blepharitis; unspecified Bronchitis; acute bronchitis 490 Bronchitis; not specified as acute or chronic Bronchitis; chronic bronchitis Cachexia Candidiasis; skin and nails Candidiasis; vulva and vagina Carbuncle and furuncle Cardiomyopathy; secondary cardiomyopathy, unspecified Cataract; infantile, juvenile, and presenile cataract Cataract; senile cataract Cholangitis Choledocholithiasis; calculus of bile duct without mention of cholecystitis Coma Convulsions, febrile, unspecified, complex, other Cushing s syndrome Cystitis, unspecified Degeneration of macula and posterior pole Degeneration; peripheral retinal degenerations Degenerative; skin disorders Delirium due to conditions classified elsewhere Diabetes mellitus complicating pregnancy, childbirth or the puerperium; unspecified as to episode of care or not applicable Diabetes mellitus complicating pregnancy, childbirth or the puerperium; antepartum Diabetes mellitus complicating pregnancy, childbirth or the puerperium; postpartum Diabetes mellitus Diabetes, secondary Diarrhea Disease; nervous system, unspecified disorder of autonomic nervous system Medicare Limited Coverage Tests January 2015
5 Disease; retina, other retinal disorders Disorders of carbohydrate transport and metabolism Disorders of fluid, electrolyte, and acid-base balance Disorders of iron metabolism Disorders of lipoid metabolism Disorders; of the pituitary gland and its hypothalamic control Disorders; other disorders of pancreatic internal secretion Disorders; other disorders unspecified retinol Disturbance of skin sensation Disturbance of salivary secretion Disturbance; other specified visual disturbances Dizziness and giddiness Dyspepsia and other specified disorders of function of stomach Dyspnea and respiratory abnormalities; other Encephalopathy, metabolic Epilepsy; generalized convulsive epilepsy Excess; eating; polyphagia Fibrosis; other specified disorders of male genital organs, other V67.2 Follow-up; following chemotherapy V67.51 Follow-up; following completed treatment with high-risk medications, not elsewhere classified Frequency of urination and polyuria Gallbladder; other disorders of gallbladder Gangrene Gastritis; unspecified gastritis and gastroduodenitits Glaucoma; ocular hypertension Glaucoma; residual stage Glycosuria Hepatomegaly Hirsutism Hypercarotinemia Hyperhidrosis; generalized Hyperventilation Hypotension; orthostatic hypotension Impaired, cognitive, mild, so stated Impotence of organic origin Incontinence of feces Infarction; acute myocardial infarction 118 Infection; opportunistic mycoses Infection; other local infections of skin and subcutaneous tissue Infections of kidney Infertility; of unspecified origin Irregular menstrual cycle Ischemic; other forms fo chronic ischemic heart disease V58.63-V58.65 Long-term (current) use of drugs, antiplatelets,non-steroidal anti-inflammatories, steroid V58.67 Long-term (current) use of insulin V58.69 Long-term (current) use of other medications Malaise and fatigue, functional quadriplegia, other malaise and fatigue Malnutrition; other and unspecified protein-calorie malnutrition Mononeuritis of unspecified site Myalgia and myositis, unspecified Myopia Neoplasm; malignant, benign, islets of Langerhans Neoplasm; malignant, primary, islets of Langerhans Neoplasm; malignant, primary, retroperitoneum Neuropathy; hereditary and idiopathic peripheral neuropathy; unspecified Neurosis, neurotic; unspecified nonpsychotic mental disorders Osteomyelitis of ankle and foot; acute Osteomyelitis of ankle and foot; chronic Osteomyelitis of ankle and foot; unspecified January 2015 Medicare Limited Coverage Tests
6 Pains; chest pain, unspecified Pancreatitis; acute pancreatitis Pancreatitis; chronic pancreatitis Pancreatitis; fibrous, other specified diseases of pancreas Paralysis of bladder 462 Pharyngitis; acute pharyngitis Pneumonia and influenza Polydipsia Polyhydramnios Polyneuropathy; inflammatory and toxin neuropathy; unspecified Pregnancy, excessive fetal growth V23.0-V23.9 Pregnancy; supervision of high-risk pregnancy Proteinuria Pruritus ani Pruritus of genital organs Pseudopapilledema Psychosis; unspecified persistent mental disorders due to conditions classified elsewhere Psychosis; unspecified psychosis Retinopathy; other nondiabetic proliferative retinopathy Retinopathy; circinate, background retinopathy, unspecified V77.1 Special Screening for endocrine, nutrition, metabolic & immunity disorders (Covered for procedure code only) Septicemia Stomatitis and mucositis, unspecified Stomatitis and mucositis (ulcerative), other Strabismus; paralytic strabismus Syncope and collapse Syndrome; personality change due to conditions classified elsewhere Tachycardia, unspecified Thyrotoxicosis with or without goiter Tuberculosis; pulmonary Ulcer; chronic ulcer of skin Unspecified disorder of optic nerve and visual pathways Urinary tract infection, site not specified Vaginitis and vulvoaginitis, unspecified Vasculitis; retinal vasculitis Yellow; yellow fever, other chronic nonalcoholic liver disease Medicare Limited Coverage Tests Covered Diagnosis Codes Source: National Coverage Determinations January 2013 Coding Policy Manual and Change Report Medicare Limited Coverage Tests January 2015
NCD for Lipids Testing
Applicable CPT Code(s): NCD for Lipids Testing 80061 Lipid panel 82465 Cholesterol, serum or whole blood, total 83700 Lipoprotein, blood; electrophoretic separation and quantitation 83701 Lipoprotein blood;
LIPID PANEL CHOLESTEROL LIPOPROTEIN, ELECTROPHORETIC SEPARATION LIPOPROTEIN, DIRECT MEASUREMENT (HDL) LDL DIRECT TRIGLYCERIDES
Test Code Test Name CPT CHOL Cholesterol, Serum 82465 HDL HDL, (High Density Lipoprotein) 83718 TRIG Triglycerides, Serum 84478 FTRIG Triglycerides (Fluid) 84478 LIPID Lipid Panel 80061 LDL LDL (Low Density
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THYROID FUNCTION TESTING THYROID STIMULATING HORMONE THYROXINE; FREE, (T4) THYROXINE; TOTAL, (T4) TRIIODOTHYRONINE (T3); RESIN UPTAKE
Test Code Test Name CPT T4 Thyroxine; Total (T4) 84436 T4FRE Thyroxine; Free (T4 free) 84439 T4FR T4 Free Dialysis 84439 TSH Thyroid Stimulating Hormone (TSH) 84443 T3UP Triiodothyronine (T3); Resin uptake
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