Local Coverage Determination (LCD): Immunohistochemistry (L34369)

Transcription

1 Local Coverage Determination (LCD): Immunohistochemistry (L34369) Contractor Information Contractor Name CGS Administrators, LLC LCD Information Document Information LCD ID L34369 Original ICD9 LCD ID L31873 LCD Title Immunohistochemistry AMA CPT/ADA CDT Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and Original Effective Date For services performed on or after 10/01/2014 Revision Effective Date For services performed on or after 10/01/2014 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A

2 CDT2010 are trademarks of the American Dental Association. CMS National Coverage Policy Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act (SSA): Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Code of Federal Regulations: 42 CFR, Section , indicates that diagnostic tests may only be ordered by the treating physician (or other treating practitioner acting within the scope of his or her license and Medicare requirements)who furnishes a consultation or treats a beneficiary for a specific medical problem and who uses the results in the management of the beneficiary's specific medical problem. Tests not ordered by the physician (or other qualified nonphysician provider) who is treating the beneficiary are not reasonable and necessary (see Sec (k)(1) of this chapter). A pathologist may perform additional tests under the following circumstances: These services are medically necessary so that a complete and accurate diagnosis can be reported to the treating physician/practitioner; The results of the tests are communicated to and are used by the treating physician/practitioner in the treatment of the beneficiary; and The pathologist documents in his/her report why additional testing was done. CMS Transmittal No. 1770, Publication , Medicare Claims Processing Manual, Change Request #6520, July 10, 2009, Medicare contractor annual update of the international classification of diseases, ninth revision, clinical modification (ICD9CM).

3 Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Abstract: Immunohistochemistry (IHC) combines anatomical, immunological and biochemical techniques for the identification of specific tissue components by means of a specific antigen/antibody reaction tagged with a visible label. IHC makes it possible to visualize the distribution and localization of specific cellular components within a cell or tissue. The principle of immunohistochemistry has existed since the 1930s, but it was not until 1942 that the first immunohistochemistry study was reported. Coons and his colleagues used labeled antibodies to localize Pneumococcal antigens in infected tissues. Since then improvements have been made in protein conjugation, tissue fixation methods, detection labels and microscopes, making immunohistochemistry an essential tool in many laboratories. Today, the most popular methods of detection are with enzymeantibody and fluorophoreantibody conjugates. After the antigenantibody reaction, the enzyme label is reacted with a substrate to yield an intensely colored product that can be analyzed with an ordinary light microscope. A further advantage of using enzyme labeled systems is the option to make the product electron dense for electron microscopy. This LCD documents CGS approved indications and limitations of coverage for this laboratory test. Indications: Immunohistochemistry is useful in the evaluation of various malignancies, for diagnosis, staging, and the estimation of prognosis. It is also useful for the identification of a number of infectious organisms. Limitations: It is unusual to require more than 10 immunohistochemical analyses in order to adequately evaluate a sample of tissue. Utilization beyond this threshold should be supported in the medical record, and may be subject to review. Other Comments: For claims submitted to the Part A MAC: this coverage determination also applies within states outside the primary geographic jurisdiction with facilities that have nominated CGS Administrators, LLC to process their claims. Bill type codes only apply to providers who bill these services to the Part A MAC. Bill type codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC. Limitation of liability and refund requirements apply when denials are likely, whether based on medical necessity or other coverage reasons. The provider/supplier must notify the beneficiary in

4 writing, prior to rendering the service, if the provider/supplier is aware that the test, item or procedure may not be covered by Medicare. The limitation of liability and refund requirements do not apply when the test, item or procedure is statutorily excluded, has no Medicare benefit category or is rendered for screening purposes. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services. For outpatient settings other than CORFs, references to "physicians" throughout this policy include nonphysicians, such as nurse practitioners, clinical nurse specialists and physician assistants. Such nonphysician practitioners, with certain exceptions, may certify, order and establish the plan of care for services as authorized by State law. (See Sections 1861[s][2] and 1862[a][14] of Title XVIII of the Social Security Act; 42 CFR, Sections , , and ; 58 FR 18543, April 7, 2000.) Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 011x Hospital Inpatient (Including Medicare Part A) 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 014x Hospital Laboratory Services Provided to Nonpatients 021x Skilled Nursing Inpatient (Including Medicare Part A) 022x Skilled Nursing Inpatient (Medicare Part B only) 023x Skilled Nursing Outpatient 071x Clinic Rural Health 073x Clinic Freestanding 077x Clinic Federally Qualified Health Center (FQHC) 085x Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

5 Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes. All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review Laboratory Pathology General Classification 0311 Laboratory Pathology Cytology 0312 Laboratory Pathology Histology 0314 Laboratory Pathology Biopsy 0319 Laboratory Pathology Other Laboratory Pathology 0521 FreeStanding Clinic Clinic Visit by Member to RHC/FQHC 096X Professional Fees General Classification 0971 Professional Fees Laboratory CPT/HCPCS Codes Group 1 Paragraph: N/A Group 1 Codes: IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, PER SPECIMEN; G0461 FIRST SINGLE OR MULTIPLEX ANTIBODY STAIN IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, PER SPECIMEN; G0462 EACH ADDITIONAL SINGLE OR MULTIPLEX ANTIBODY STAIN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ICD10 Codes that Support Medical Necessity Group 1 Paragraph: It is the responsibility of the provider to code to the highest level specified in the ICD10CM. The correct use of an ICD10CM code does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination. Group 1 Codes:

6 Group 1Codes ICD10 Code Description A18.14 Tuberculosis of prostate A63.0 Anogenital (venereal) warts A74.9 Chlamydial infection, unspecified B07.8 Other viral warts B07.9 Viral wart, unspecified B15.0 Hepatitis A with hepatic coma B15.9 Hepatitis A without hepatic coma B16.0 B16.2 Acute hepatitis B with deltaagent with hepatic coma Acute hepatitis B without deltaagent with hepatic coma B16.9 Acute hepatitis B without deltaagent and without hepatic coma B17.0 Acute delta(super) infection of hepatitis B carrier B17.10 Acute hepatitis C without hepatic coma B17.11 Acute hepatitis C with hepatic coma B17.2 Acute hepatitis E B17.8 Other specified acute viral hepatitis B18.0 B18.2 Chronic viral hepatitis B with deltaagent Chronic viral hepatitis C B18.8 Other chronic viral hepatitis B19.0 Unspecified viral hepatitis with hepatic coma B19.10 Unspecified viral hepatitis B without hepatic coma B19.11 Unspecified viral hepatitis B with hepatic coma B19.20 Unspecified viral hepatitis C without hepatic coma B19.21 Unspecified viral hepatitis C with hepatic coma B25.1 Cytomegaloviral hepatitis B25.2 Cytomegaloviral pancreatitis B33.8 Other specified viral diseases B34.1 B34.4 Enterovirus infection, unspecified Papovavirus infection, unspecified B34.8 Other viral infections of unspecified site B96.81 Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere B97.19 Other enterovirus as the cause of diseases classified elsewhere B97.29 Other coronavirus as the cause of diseases classified elsewhere B97.5 B97.7 Reovirus as the cause of diseases classified elsewhere Papillomavirus as the cause of diseases classified elsewhere B97.81 Human metapneumovirus as the cause of diseases classified elsewhere B97.89 Other viral agents as the cause of diseases classified elsewhere C00.0 C00.9 Malignant neoplasm of external upper lip Malignant neoplasm of lip, unspecified C01 Malignant neoplasm of base of tongue

7 C02.0 C02.4 Malignant neoplasm of dorsal surface of tongue Malignant neoplasm of lingual tonsil C02.8 Malignant neoplasm of overlapping sites of tongue C02.9 Malignant neoplasm of tongue, unspecified C03.0 Malignant neoplasm of upper gum C03.1 Malignant neoplasm of lower gum C03.9 Malignant neoplasm of gum, unspecified C04.0 Malignant neoplasm of anterior floor of mouth C04.1 Malignant neoplasm of lateral floor of mouth C04.8 Malignant neoplasm of overlapping sites of floor of mouth C04.9 Malignant neoplasm of floor of mouth, unspecified C05.0 C05.2 Malignant neoplasm of hard palate Malignant neoplasm of uvula C05.8 Malignant neoplasm of overlapping sites of palate C06.0 C06.2 Malignant neoplasm of cheek mucosa Malignant neoplasm of retromolar area C06.89 Malignant neoplasm of overlapping sites of other parts of mouth C06.9 Malignant neoplasm of mouth, unspecified C07 Malignant neoplasm of parotid gland C08.0 Malignant neoplasm of submandibular gland C08.1 Malignant neoplasm of sublingual gland C08.9 Malignant neoplasm of major salivary gland, unspecified C09.0 Malignant neoplasm of tonsillar fossa C09.1 Malignant neoplasm of tonsillar pillar (anterior) (posterior) C09.8 Malignant neoplasm of overlapping sites of tonsil C10.0 C10.4 Malignant neoplasm of vallecula Malignant neoplasm of branchial cleft C10.8 Malignant neoplasm of overlapping sites of oropharynx C10.9 Malignant neoplasm of oropharynx, unspecified C11.0 C11.3 Malignant neoplasm of superior wall of nasopharynx Malignant neoplasm of anterior wall of nasopharynx C11.8 Malignant neoplasm of overlapping sites of nasopharynx C11.9 Malignant neoplasm of nasopharynx, unspecified C12 Malignant neoplasm of pyriform sinus C13.0 C13.2 Malignant neoplasm of postcricoid region Malignant neoplasm of posterior wall of hypopharynx C13.8 Malignant neoplasm of overlapping sites of hypopharynx C13.9 Malignant neoplasm of hypopharynx, unspecified C14.0 Malignant neoplasm of pharynx, unspecified C14.2 Malignant neoplasm of Waldeyer's ring C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx C15.3 C15.5 Malignant neoplasm of upper third of esophagus Malignant neoplasm of lower third of esophagus

8 C15.8 Malignant neoplasm of overlapping sites of esophagus C15.9 Malignant neoplasm of esophagus, unspecified C16.0 C16.6 Malignant neoplasm of cardia Malignant neoplasm of greater curvature of stomach, unspecified C16.8 Malignant neoplasm of overlapping sites of stomach C16.9 Malignant neoplasm of stomach, unspecified C17.0 C17.3 Malignant neoplasm of duodenum Meckel's diverticulum, malignant C17.8 Malignant neoplasm of overlapping sites of small intestine C17.9 Malignant neoplasm of small intestine, unspecified C18.0 C18.9 Malignant neoplasm of cecum Malignant neoplasm of colon, unspecified C19 Malignant neoplasm of rectosigmoid junction C20 Malignant neoplasm of rectum C21.0 C21.2 Malignant neoplasm of anus, unspecified Malignant neoplasm of cloacogenic zone C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal C22.0 C22.4 Liver cell carcinoma Other sarcomas of liver C22.7 Other specified carcinomas of liver C22.9 Malignant neoplasm of liver, not specified as primary or secondary C23 Malignant neoplasm of gallbladder C24.0 Malignant neoplasm of extrahepatic bile duct C24.1 Malignant neoplasm of ampulla of Vater C24.8 Malignant neoplasm of overlapping sites of biliary tract C24.9 Malignant neoplasm of biliary tract, unspecified C25.0 C25.4 Malignant neoplasm of head of pancreas Malignant neoplasm of endocrine pancreas C25.7 Malignant neoplasm of other parts of pancreas C25.8 Malignant neoplasm of overlapping sites of pancreas C25.9 Malignant neoplasm of pancreas, unspecified C26.0 Malignant neoplasm of intestinal tract, part unspecified C26.1 Malignant neoplasm of spleen C26.9 Malignant neoplasm of illdefined sites within the digestive system C30.0 Malignant neoplasm of nasal cavity C30.1 Malignant neoplasm of middle ear C31.0 C31.3 Malignant neoplasm of maxillary sinus Malignant neoplasm of sphenoid sinus C31.8 Malignant neoplasm of overlapping sites of accessory sinuses C31.9 Malignant neoplasm of accessory sinus, unspecified C32.0 C32.3 Malignant neoplasm of glottis Malignant neoplasm of laryngeal cartilage C32.8 Malignant neoplasm of overlapping sites of larynx

9 C32.9 Malignant neoplasm of larynx, unspecified C33 Malignant neoplasm of trachea C34.01 Malignant neoplasm of right main bronchus C34.02 Malignant neoplasm of left main bronchus 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 C34.31 Malignant neoplasm of lower lobe, right bronchus or lung C34.32 Malignant neoplasm of lower lobe, left bronchus or 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 C34.91 Malignant neoplasm of unspecified part of right bronchus or lung C34.92 Malignant neoplasm of unspecified part of left bronchus or lung C37 Malignant neoplasm of thymus C38.0 C38.4 Malignant neoplasm of heart Malignant neoplasm of pleura C38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleura C39.0 Malignant neoplasm of upper respiratory tract, part unspecified C39.9 Malignant neoplasm of lower respiratory tract, part unspecified C40.01 Malignant neoplasm of scapula and long bones of right upper limb C40.02 Malignant neoplasm of scapula and long bones of left upper limb C40.11 Malignant neoplasm of short bones of right upper limb C40.12 Malignant neoplasm of short bones of left upper limb C40.21 Malignant neoplasm of long bones of right lower limb C40.22 Malignant neoplasm of long bones of left lower limb C40.31 Malignant neoplasm of short bones of right lower limb C40.32 Malignant neoplasm of short bones of left lower limb C40.81 Malignant neoplasm of overlapping sites of bone and articular cartilage of right limb C40.82 Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb C40.91 Malignant neoplasm of unspecified bones and articular cartilage of right limb C40.92 Malignant neoplasm of unspecified bones and articular cartilage of left limb C41.0 C41.4 Malignant neoplasm of bones of skull and face Malignant neoplasm of pelvic bones, sacrum and coccyx C43.0 Malignant melanoma of lip C43.11 Malignant melanoma of right eyelid, including canthus C43.12 Malignant melanoma of left eyelid, including canthus C43.21 Malignant melanoma of right ear and external auricular canal C43.22 Malignant melanoma of left ear and external auricular canal C43.30 Malignant melanoma of unspecified part of face C43.31 Malignant melanoma of nose

10 C43.39 Malignant melanoma of other parts of face C43.4 Malignant melanoma of scalp and neck C43.51 Malignant melanoma of anal skin C43.52 Malignant melanoma of skin of breast C43.59 Malignant melanoma of other part of trunk C43.61 Malignant melanoma of right upper limb, including shoulder C43.62 Malignant melanoma of left upper limb, including shoulder C43.71 Malignant melanoma of right lower limb, including hip C43.72 Malignant melanoma of left lower limb, including hip C43.8 Malignant melanoma of overlapping sites of skin C43.9 Malignant melanoma of skin, unspecified C44.00 C44.02 Unspecified malignant neoplasm of skin of lip Squamous cell carcinoma of skin of lip C44.09 Other specified malignant neoplasm of skin of lip C Unspecified malignant neoplasm of skin of right eyelid, including canthus C Unspecified malignant neoplasm of skin of left eyelid, including canthus C Basal cell carcinoma of skin of right eyelid, including canthus C Basal cell carcinoma of skin of left eyelid, including canthus C Squamous cell carcinoma of skin of right eyelid, including canthus C Squamous cell carcinoma of skin of left eyelid, including canthus C Other specified malignant neoplasm of skin of right eyelid, including canthus C Other specified malignant neoplasm of skin of left eyelid, including canthus C Unspecified malignant neoplasm of skin of right ear and external auricular canal C Unspecified malignant neoplasm of skin of left ear and external auricular canal C Basal cell carcinoma of skin of right ear and external auricular canal C Basal cell carcinoma of skin of left ear and external auricular canal C Squamous cell carcinoma of skin of right ear and external auricular canal C Squamous cell carcinoma of skin of left ear and external auricular canal C Other specified malignant neoplasm of skin of right ear and external auricular canal C Other specified malignant neoplasm of skin of left ear and external auricular canal C Unspecified malignant neoplasm of skin of unspecified part of face C Unspecified malignant neoplasm of skin of nose C Unspecified malignant neoplasm of skin of other parts of face C Basal cell carcinoma of skin of unspecified parts of face C Basal cell carcinoma of skin of nose C Basal cell carcinoma of skin of other parts of face C Squamous cell carcinoma of skin of unspecified parts of face C Squamous cell carcinoma of skin of nose C Squamous cell carcinoma of skin of other parts of face C Other specified malignant neoplasm of skin of unspecified parts of face C Other specified malignant neoplasm of skin of nose

11 C Other specified malignant neoplasm of skin of other parts of face C44.40 C44.42 Unspecified malignant neoplasm of skin of scalp and neck Squamous cell carcinoma of skin of scalp and neck C44.49 Other specified malignant neoplasm of skin of scalp and neck C Unspecified malignant neoplasm of anal skin C Unspecified malignant neoplasm of skin of breast C Unspecified malignant neoplasm of skin of other part of trunk C Basal cell carcinoma of anal skin C Basal cell carcinoma of skin of breast C Basal cell carcinoma of skin of other part of trunk C Squamous cell carcinoma of anal skin C Squamous cell carcinoma of skin of breast C Squamous cell carcinoma of skin of other part of trunk C Other specified malignant neoplasm of anal skin C Other specified malignant neoplasm of skin of breast C Other specified malignant neoplasm of skin of other part of trunk C Unspecified malignant neoplasm of skin of right upper limb, including shoulder C Unspecified malignant neoplasm of skin of left upper limb, including shoulder C Basal cell carcinoma of skin of right upper limb, including shoulder C Basal cell carcinoma of skin of left upper limb, including shoulder C Squamous cell carcinoma of skin of right upper limb, including shoulder C Squamous cell carcinoma of skin of left upper limb, including shoulder C Other specified malignant neoplasm of skin of right upper limb, including shoulder C Other specified malignant neoplasm of skin of left upper limb, including shoulder C Unspecified malignant neoplasm of skin of right lower limb, including hip C Unspecified malignant neoplasm of skin of left lower limb, including hip C Basal cell carcinoma of skin of right lower limb, including hip C Basal cell carcinoma of skin of left lower limb, including hip C Squamous cell carcinoma of skin of right lower limb, including hip C Squamous cell carcinoma of skin of left lower limb, including hip C Other specified malignant neoplasm of skin of right lower limb, including hip C Other specified malignant neoplasm of skin of left lower limb, including hip C44.80 C44.82 Unspecified malignant neoplasm of overlapping sites of skin Squamous cell carcinoma of overlapping sites of skin C44.89 Other specified malignant neoplasm of overlapping sites of skin C44.90 C44.92 Unspecified malignant neoplasm of skin, unspecified Squamous cell carcinoma of skin, unspecified C44.99 Other specified malignant neoplasm of skin, unspecified C45.0 C45.2 Mesothelioma of pleura Mesothelioma of pericardium C45.7 Mesothelioma of other sites

12 C45.9 Mesothelioma, unspecified C46.0 C46.4 Kaposi's sarcoma of skin Kaposi's sarcoma of gastrointestinal sites C46.51 Kaposi's sarcoma of right lung C46.52 Kaposi's sarcoma of left lung C46.7 Kaposi's sarcoma of other sites C46.9 Kaposi's sarcoma, unspecified C47.0 Malignant neoplasm of peripheral nerves of head, face and neck C47.11 Malignant neoplasm of peripheral nerves of right upper limb, including shoulder C47.12 Malignant neoplasm of peripheral nerves of left upper limb, including shoulder C47.21 Malignant neoplasm of peripheral nerves of right lower limb, including hip C47.22 Malignant neoplasm of peripheral nerves of left lower limb, including hip C47.3 C47.6 Malignant neoplasm of peripheral nerves of thorax Malignant neoplasm of peripheral nerves of trunk, unspecified C47.8 Malignant neoplasm of overlapping sites of peripheral nerves and autonomic nervous system C47.9 Malignant neoplasm of peripheral nerves and autonomic nervous system, unspecified C48.0 C48.2 Malignant neoplasm of retroperitoneum Malignant neoplasm of peritoneum, unspecified C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck C49.11 Malignant neoplasm of connective and soft tissue of right upper limb, including shoulder C49.12 Malignant neoplasm of connective and soft tissue of left upper limb, including shoulder C49.21 Malignant neoplasm of connective and soft tissue of right lower limb, including hip C49.22 Malignant neoplasm of connective and soft tissue of left lower limb, including hip C49.3 C49.6 Malignant neoplasm of connective and soft tissue of thorax Malignant neoplasm of connective and soft tissue of trunk, unspecified C49.8 Malignant neoplasm of overlapping sites of connective and soft tissue C49.9 Malignant neoplasm of connective and soft tissue, unspecified C4A.0 Merkel cell carcinoma of lip C4A.11 Merkel cell carcinoma of right eyelid, including canthus C4A.12 Merkel cell carcinoma of left eyelid, including canthus C4A.21 Merkel cell carcinoma of right ear and external auricular canal C4A.22 Merkel cell carcinoma of left ear and external auricular canal C4A.30 Merkel cell carcinoma of unspecified part of face C4A.31 Merkel cell carcinoma of nose C4A.39 Merkel cell carcinoma of other parts of face C4A.4 Merkel cell carcinoma of scalp and neck C4A.51 Merkel cell carcinoma of anal skin

13 C4A.52 Merkel cell carcinoma of skin of breast C4A.59 Merkel cell carcinoma of other part of trunk C4A.61 Merkel cell carcinoma of right upper limb, including shoulder C4A.62 Merkel cell carcinoma of left upper limb, including shoulder C4A.71 Merkel cell carcinoma of right lower limb, including hip C4A.72 Merkel cell carcinoma of left lower limb, including hip C4A.8 Merkel cell carcinoma of overlapping sites C Malignant neoplasm of nipple and areola, right female breast C Malignant neoplasm of nipple and areola, left female breast C Malignant neoplasm of nipple and areola, right male breast C Malignant neoplasm of nipple and areola, left male breast C Malignant neoplasm of central portion of right female breast C Malignant neoplasm of central portion of left female breast C Malignant neoplasm of central portion of right male breast C Malignant neoplasm of central portion of left male breast C Malignant neoplasm of upperinner quadrant of right female breast C Malignant neoplasm of upperinner quadrant of left female breast C Malignant neoplasm of upperinner quadrant of right male breast C Malignant neoplasm of upperinner quadrant of left male breast C Malignant neoplasm of lowerinner quadrant of right female breast C Malignant neoplasm of lowerinner quadrant of left female breast C Malignant neoplasm of lowerinner quadrant of right male breast C Malignant neoplasm of lowerinner quadrant of left male breast C Malignant neoplasm of upperouter quadrant of right female breast C Malignant neoplasm of upperouter quadrant of left female breast C Malignant neoplasm of upperouter quadrant of right male breast C Malignant neoplasm of upperouter quadrant of left male breast C Malignant neoplasm of lowerouter quadrant of right female breast C Malignant neoplasm of lowerouter quadrant of left female breast C Malignant neoplasm of lowerouter quadrant of right male breast C Malignant neoplasm of lowerouter quadrant of left male breast C Malignant neoplasm of axillary tail of right female breast C Malignant neoplasm of axillary tail of left female breast C Malignant neoplasm of axillary tail of right male breast C Malignant neoplasm of axillary tail of left male breast C Malignant neoplasm of overlapping sites of right female breast C Malignant neoplasm of overlapping sites of left female breast C Malignant neoplasm of overlapping sites of right male breast C Malignant neoplasm of overlapping sites of left male breast C Malignant neoplasm of unspecified site of right female breast C Malignant neoplasm of unspecified site of left female breast C Malignant neoplasm of unspecified site of right male breast

14 C Malignant neoplasm of unspecified site of left male breast C51.0 C51.2 Malignant neoplasm of labium majus Malignant neoplasm of clitoris C51.8 Malignant neoplasm of overlapping sites of vulva C51.9 Malignant neoplasm of vulva, unspecified C52 Malignant neoplasm of vagina C53.0 Malignant neoplasm of endocervix C53.1 Malignant neoplasm of exocervix C53.8 Malignant neoplasm of overlapping sites of cervix uteri C53.9 Malignant neoplasm of cervix uteri, unspecified C54.0 C54.3 Malignant neoplasm of isthmus uteri Malignant neoplasm of fundus uteri C54.8 Malignant neoplasm of overlapping sites of corpus uteri C55 Malignant neoplasm of uterus, part unspecified C56.1 Malignant neoplasm of right ovary C56.2 Malignant neoplasm of left ovary C57.01 Malignant neoplasm of right fallopian tube C57.02 Malignant neoplasm of left fallopian tube C57.11 Malignant neoplasm of right broad ligament C57.12 Malignant neoplasm of left broad ligament C57.21 Malignant neoplasm of right round ligament C57.22 Malignant neoplasm of left round ligament C57.3 Malignant neoplasm of parametrium C57.4 Malignant neoplasm of uterine adnexa, unspecified C57.7 C57.9 Malignant neoplasm of other specified female genital organs Malignant neoplasm of female genital organ, unspecified C58 Malignant neoplasm of placenta C60.0 C60.2 Malignant neoplasm of prepuce Malignant neoplasm of body of penis C60.8 Malignant neoplasm of overlapping sites of penis C60.9 Malignant neoplasm of penis, unspecified C61 Malignant neoplasm of prostate C62.01 Malignant neoplasm of undescended right testis C62.02 Malignant neoplasm of undescended left testis C62.11 Malignant neoplasm of descended right testis C62.12 Malignant neoplasm of descended left testis C62.91 Malignant neoplasm of right testis, unspecified whether descended or undescended C62.92 Malignant neoplasm of left testis, unspecified whether descended or undescended C63.01 Malignant neoplasm of right epididymis C63.02 Malignant neoplasm of left epididymis C63.11 Malignant neoplasm of right spermatic cord

15 C63.12 Malignant neoplasm of left spermatic cord C63.2 Malignant neoplasm of scrotum C63.7 C63.9 Malignant neoplasm of other specified male genital organs Malignant neoplasm of male genital organ, unspecified C64.1 Malignant neoplasm of right kidney, except renal pelvis C64.2 Malignant neoplasm of left kidney, except renal pelvis C65.1 Malignant neoplasm of right renal pelvis C65.2 Malignant neoplasm of left renal pelvis C66.1 Malignant neoplasm of right ureter C66.2 Malignant neoplasm of left ureter C67.0 C67.9 Malignant neoplasm of trigone of bladder Malignant neoplasm of bladder, unspecified C68.0 Malignant neoplasm of urethra C68.1 Malignant neoplasm of paraurethral glands C68.8 Malignant neoplasm of overlapping sites of urinary organs C68.9 Malignant neoplasm of urinary organ, unspecified C69.01 Malignant neoplasm of right conjunctiva C69.02 Malignant neoplasm of left conjunctiva C69.11 Malignant neoplasm of right cornea C69.12 Malignant neoplasm of left cornea C69.21 Malignant neoplasm of right retina C69.22 Malignant neoplasm of left retina C69.31 Malignant neoplasm of right choroid C69.32 Malignant neoplasm of left choroid C69.41 Malignant neoplasm of right ciliary body C69.42 Malignant neoplasm of left ciliary body C69.51 Malignant neoplasm of right lacrimal gland and duct C69.52 Malignant neoplasm of left lacrimal gland and duct C69.61 Malignant neoplasm of right orbit C69.62 Malignant neoplasm of left orbit C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa C69.91 Malignant neoplasm of unspecified site of right eye C69.92 Malignant neoplasm of unspecified site of left eye C70.0 Malignant neoplasm of cerebral meninges C70.1 Malignant neoplasm of spinal meninges C71.0 C71.9 Malignant neoplasm of cerebrum, except lobes and ventricles Malignant neoplasm of brain, unspecified C72.0 Malignant neoplasm of spinal cord C72.1 Malignant neoplasm of cauda equina C72.21 Malignant neoplasm of right olfactory nerve C72.22 Malignant neoplasm of left olfactory nerve

16 C72.31 Malignant neoplasm of right optic nerve C72.32 Malignant neoplasm of left optic nerve C72.41 Malignant neoplasm of right acoustic nerve C72.42 Malignant neoplasm of left acoustic nerve C72.50 Malignant neoplasm of unspecified cranial nerve C72.59 Malignant neoplasm of other cranial nerves C72.9 Malignant neoplasm of central nervous system, unspecified C73 Malignant neoplasm of thyroid gland C74.01 Malignant neoplasm of cortex of right adrenal gland C74.02 Malignant neoplasm of cortex of left adrenal gland C74.11 Malignant neoplasm of medulla of right adrenal gland C74.12 Malignant neoplasm of medulla of left adrenal gland C74.91 Malignant neoplasm of unspecified part of right adrenal gland C74.92 Malignant neoplasm of unspecified part of left adrenal gland C75.0 C75.5 Malignant neoplasm of parathyroid gland Malignant neoplasm of aortic body and other paraganglia C75.8 Malignant neoplasm with pluriglandular involvement, unspecified C75.9 Malignant neoplasm of endocrine gland, unspecified C76.0 C76.3 Malignant neoplasm of head, face and neck Malignant neoplasm of pelvis C76.41 Malignant neoplasm of right upper limb C76.42 Malignant neoplasm of left upper limb C76.51 Malignant neoplasm of right lower limb C76.52 Malignant neoplasm of left lower limb C76.8 Malignant neoplasm of other specified illdefined sites C77.0 C77.5 Secondary and unspecified malignant neoplasm of lymph nodes of head, face and neck Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes C77.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple regions C77.9 Secondary and unspecified malignant neoplasm of lymph node, unspecified C78.01 Secondary malignant neoplasm of right lung C78.02 Secondary malignant neoplasm of left lung C78.1 Secondary malignant neoplasm of mediastinum C78.2 Secondary malignant neoplasm of pleura C78.39 Secondary malignant neoplasm of other respiratory organs C78.4 C78.7 Secondary malignant neoplasm of small intestine Secondary malignant neoplasm of liver and intrahepatic bile duct C78.89 Secondary malignant neoplasm of other digestive organs C79.01 Secondary malignant neoplasm of right kidney and renal pelvis C79.02 Secondary malignant neoplasm of left kidney and renal pelvis C79.10 Secondary malignant neoplasm of unspecified urinary organs C79.11 Secondary malignant neoplasm of bladder

17 C79.19 Secondary malignant neoplasm of other urinary organs C79.2 Secondary malignant neoplasm of skin C79.31 Secondary malignant neoplasm of brain C79.32 Secondary malignant neoplasm of cerebral meninges C79.49 Secondary malignant neoplasm of other parts of nervous system C79.51 Secondary malignant neoplasm of bone C79.52 Secondary malignant neoplasm of bone marrow C79.61 Secondary malignant neoplasm of right ovary C79.62 Secondary malignant neoplasm of left ovary C79.71 Secondary malignant neoplasm of right adrenal gland C79.72 Secondary malignant neoplasm of left adrenal gland C79.81 Secondary malignant neoplasm of breast C79.82 Secondary malignant neoplasm of genital organs C79.89 Secondary malignant neoplasm of other specified sites C7A.00 Malignant carcinoid tumor of unspecified site C7A.010 Malignant carcinoid tumor of the duodenum C7A.011 Malignant carcinoid tumor of the jejunum C7A.012 Malignant carcinoid tumor of the ileum C7A.019 Malignant carcinoid tumor of the small intestine, unspecified portion C7A.020 Malignant carcinoid tumor of the appendix C7A.021 Malignant carcinoid tumor of the cecum C7A.022 Malignant carcinoid tumor of the ascending colon C7A.023 Malignant carcinoid tumor of the transverse colon C7A.024 Malignant carcinoid tumor of the descending colon C7A.025 Malignant carcinoid tumor of the sigmoid colon C7A.026 Malignant carcinoid tumor of the rectum C7A.029 Malignant carcinoid tumor of the large intestine, unspecified portion C7A.090 Malignant carcinoid tumor of the bronchus and lung C7A.091 Malignant carcinoid tumor of the thymus C7A.092 Malignant carcinoid tumor of the stomach C7A.093 Malignant carcinoid tumor of the kidney C7A.094 Malignant carcinoid tumor of the foregut NOS C7A.095 Malignant carcinoid tumor of the midgut NOS C7A.096 Malignant carcinoid tumor of the hindgut NOS C7A.098 Malignant carcinoid tumors of other sites C7A.1 Malignant poorly differentiated neuroendocrine tumors C7A.8 Other malignant neuroendocrine tumors C80.0 Disseminated malignant neoplasm, unspecified C80.1 Malignant (primary) neoplasm, unspecified C81.01 C81.09 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck Nodular lymphocyte predominant Hodgkin lymphoma, extranodal and solid organ sites

18 C81.11 C81.19 C81.21 C81.29 C81.31 C81.39 C81.41 C81.49 C81.71 C81.79 C81.91 C81.99 C82.01 C82.09 C82.11 C82.19 C82.21 C82.29 C82.31 C82.39 C82.41 C82.49 C82.51 C82.59 C82.61 C82.69 C82.81 C82.89 C82.91 C82.99 C83.01 C83.09 C83.11 C83.19 C83.31 C83.39 C83.51 C83.59 C83.71 C83.79 Nodular sclerosis classical Hodgkin lymphoma, lymph nodes of head, face, and neck Nodular sclerosis classical Hodgkin lymphoma, extranodal and solid organ sites Mixed cellularity classical Hodgkin lymphoma, lymph nodes of head, face, and neck Mixed cellularity classical Hodgkin lymphoma, extranodal and solid organ sites Lymphocyte depleted classical Hodgkin lymphoma, lymph nodes of head, face, and neck Lymphocyte depleted classical Hodgkin lymphoma, extranodal and solid organ sites Lymphocyterich classical Hodgkin lymphoma, lymph nodes of head, face, and neck Lymphocyterich classical Hodgkin lymphoma, extranodal and solid organ sites Other classical Hodgkin lymphoma, lymph nodes of head, face, and neck Other classical Hodgkin lymphoma, extranodal and solid organ sites Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck Hodgkin lymphoma, unspecified, extranodal and solid organ sites Follicular lymphoma grade I, lymph nodes of head, face, and neck Follicular lymphoma grade I, extranodal and solid organ sites Follicular lymphoma grade II, lymph nodes of head, face, and neck Follicular lymphoma grade II, extranodal and solid organ sites Follicular lymphoma grade III, unspecified, lymph nodes of head, face, and neck Follicular lymphoma grade III, unspecified, extranodal and solid organ sites Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck Follicular lymphoma grade IIIa, extranodal and solid organ sites Follicular lymphoma grade IIIb, lymph nodes of head, face, and neck Follicular lymphoma grade IIIb, extranodal and solid organ sites Diffuse follicle center lymphoma, lymph nodes of head, face, and neck Diffuse follicle center lymphoma, extranodal and solid organ sites Cutaneous follicle center lymphoma, lymph nodes of head, face, and neck Cutaneous follicle center lymphoma, extranodal and solid organ sites Other types of follicular lymphoma, lymph nodes of head, face, and neck Other types of follicular lymphoma, extranodal and solid organ sites Follicular lymphoma, unspecified, lymph nodes of head, face, and neck Follicular lymphoma, unspecified, extranodal and solid organ sites Small cell Bcell lymphoma, lymph nodes of head, face, and neck Small cell B cell lymphoma, extranodal and solid organ sites Mantle cell lymphoma, lymph nodes of head, face, and neck Mantle cell lymphoma, extranodal and solid organ sites Diffuse large Bcell lymphoma, lymph nodes of head, face, and neck Diffuse large Bcell lymphoma, extranodal and solid organ sites Lymphoblastic (diffuse) lymphoma, lymph nodes of head, face, and neck Lymphoblastic (diffuse) lymphoma, extranodal and solid organ sites Burkitt lymphoma, lymph nodes of head, face, and neck Burkitt lymphoma, extranodal and solid organ sites

19 C83.81 C83.89 C83.91 C83.99 C84.01 C84.09 C84.11 C84.19 C84.41 C84.49 C84.61 C84.69 C84.71 C84.79 C84.91 C84.99 C84.A1 C84.A2 C84.A3 C84.A4 C84.A5 C84.A6 C84.A7 C84.A8 C84.A9 C84.Z1 C84.Z2 C84.Z3 C84.Z4 C84.Z5 C84.Z6 C84.Z7 C84.Z8 C84.Z9 C85.11 C85.19 Other nonfollicular lymphoma, lymph nodes of head, face, and neck Other nonfollicular lymphoma, extranodal and solid organ sites Nonfollicular (diffuse) lymphoma, unspecified, lymph nodes of head, face, and neck Nonfollicular (diffuse) lymphoma, unspecified, extranodal and solid organ sites Mycosis fungoides, lymph nodes of head, face, and neck Mycosis fungoides, extranodal and solid organ sites Sezary disease, lymph nodes of head, face, and neck Sezary disease, extranodal and solid organ sites Peripheral Tcell lymphoma, not classified, lymph nodes of head, face, and neck Peripheral Tcell lymphoma, not classified, extranodal and solid organ sites Anaplastic large cell lymphoma, ALKpositive, lymph nodes of head, face, and neck Anaplastic large cell lymphoma, ALKpositive, extranodal and solid organ sites Anaplastic large cell lymphoma, ALKnegative, lymph nodes of head, face, and neck Anaplastic large cell lymphoma, ALKnegative, extranodal and solid organ sites Mature T/NKcell lymphomas, unspecified, lymph nodes of head, face, and neck Mature T/NKcell lymphomas, unspecified, extranodal and solid organ sites Cutaneous Tcell lymphoma, unspecified lymph nodes of head, face, and neck Cutaneous Tcell lymphoma, unspecified, intrathoracic lymph nodes Cutaneous Tcell lymphoma, unspecified, intraabdominal lymph nodes Cutaneous Tcell lymphoma, unspecified, lymph nodes of axilla and upper limb Cutaneous Tcell lymphoma, unspecified, lymph nodes of inguinal region and lower limb Cutaneous Tcell lymphoma, unspecified, intrapelvic lymph nodes Cutaneous Tcell lymphoma, unspecified, spleen Cutaneous Tcell lymphoma, unspecified, lymph nodes of multiple sites Cutaneous Tcell lymphoma, unspecified, extranodal and solid organ sites Other mature T/NKcell lymphomas, lymph nodes of head, face, and neck Other mature T/NKcell lymphomas, intrathoracic lymph nodes Other mature T/NKcell lymphomas, intraabdominal lymph nodes Other mature T/NKcell lymphomas, lymph nodes of axilla and upper limb Other mature T/NKcell lymphomas, lymph nodes of inguinal region and lower limb Other mature T/NKcell lymphomas, intrapelvic lymph nodes Other mature T/NKcell lymphomas, spleen Other mature T/NKcell lymphomas, lymph nodes of multiple sites Other mature T/NKcell lymphomas, extranodal and solid organ sites Unspecified Bcell lymphoma, lymph nodes of head, face, and neck Unspecified Bcell lymphoma, extranodal and solid organ sites

20 C85.21 C85.29 C85.81 C85.89 Mediastinal (thymic) large Bcell lymphoma, lymph nodes of head, face, and neck Mediastinal (thymic) large Bcell lymphoma, extranodal and solid organ sites Other specified types of nonhodgkin lymphoma, lymph nodes of head, face, and neck Other specified types of nonhodgkin lymphoma, extranodal and solid organ sites NonHodgkin lymphoma, unspecified, lymph nodes of head, face, and neck NonHodgkin lymphoma, unspecified, extranodal and solid organ sites Extranodal NK/Tcell lymphoma, nasal type Primary cutaneous CD30positive C85.91 C85.99 C86.0 C86.6 Tcell proliferations C88.2 C88.4 Heavy chain disease Extranodal marginal zone Bcell lymphoma of mucosaassociated lymphoid tissue [MALTlymphoma] C88.8 Other malignant immunoproliferative diseases C90.00 C90.02 Multiple myeloma not having achieved remission Multiple myeloma in relapse C90.10 Plasma cell leukemia not having achieved remission Plasma cell leukemia in C90.12 relapse C90.20 Extramedullary plasmacytoma not having achieved remission Extramedullary C90.22 plasmacytoma in relapse C90.30 Solitary plasmacytoma not having achieved remission Solitary plasmacytoma in C90.32 relapse C91.00 Acute lymphoblastic leukemia not having achieved remission Acute C91.02 lymphoblastic leukemia, in relapse C91.10 Chronic lymphocytic leukemia of Bcell type not having achieved remission C91.12 Chronic lymphocytic leukemia of Bcell type in relapse C91.30 Prolymphocytic leukemia of Bcell type not having achieved remission C91.32 Prolymphocytic leukemia of Bcell type, in relapse C91.40 Hairy cell leukemia not having achieved remission Hairy cell leukemia, in C91.42 relapse C91.50 Adult Tcell lymphoma/leukemia (HTLV1associated) not having achieved C91.52 remission Adult Tcell lymphoma/leukemia (HTLV1associated), in relapse C91.60 Prolymphocytic leukemia of Tcell type not having achieved remission C91.62 Prolymphocytic leukemia of Tcell type, in relapse C91.90 Lymphoid leukemia, unspecified not having achieved remission Lymphoid C91.92 leukemia, unspecified, in relapse C91.A0 Mature Bcell leukemia Burkitttype not having achieved remission C91.A1 Mature Bcell leukemia Burkitttype, in remission C91.A2 Mature Bcell leukemia Burkitttype, in relapse C91.Z0 Other lymphoid leukemia not having achieved remission C91.Z1 Other lymphoid leukemia, in remission C91.Z2 Other lymphoid leukemia, in relapse C92.00 Acute myeloblastic leukemia, not having achieved remission Acute myeloblastic C92.02 leukemia, in relapse

21 C92.10 C92.12 Chronic myeloid leukemia, BCR/ABLpositive, not having achieved remission Chronic myeloid leukemia, BCR/ABLpositive, in relapse C92.20 C92.22 Atypical chronic myeloid leukemia, BCR/ABLnegative, not having achieved remission Atypical chronic myeloid leukemia, BCR/ABLnegative, in relapse C92.30 C92.32 Myeloid sarcoma, not having achieved remission Myeloid sarcoma, in relapse C92.40 C92.42 Acute promyelocytic leukemia, not having achieved remission Acute promyelocytic leukemia, in relapse C92.50 C92.52 Acute myelomonocytic leukemia, not having achieved remission Acute myelomonocytic leukemia, in relapse C92.60 C92.62 Acute myeloid leukemia with 11q23abnormality not having achieved remission Acute myeloid leukemia with 11q23abnormality in relapse C92.90 C92.92 Myeloid leukemia, unspecified, not having achieved remission Myeloid leukemia, unspecified in relapse C92.A0 Acute myeloid leukemia with multilineage dysplasia, not having achieved remission C92.A1 Acute myeloid leukemia with multilineage dysplasia, in remission C92.A2 Acute myeloid leukemia with multilineage dysplasia, in relapse C92.Z0 Other myeloid leukemia not having achieved remission C92.Z1 Other myeloid leukemia, in remission C92.Z2 Other myeloid leukemia, in relapse C93.00 C93.02 Acute monoblastic/monocytic leukemia, not having achieved remission Acute monoblastic/monocytic leukemia, in relapse C93.10 C93.12 Chronic myelomonocytic leukemia not having achieved remission Chronic myelomonocytic leukemia, in relapse C93.30 C93.32 Juvenile myelomonocytic leukemia, not having achieved remission Juvenile myelomonocytic leukemia, in relapse C93.90 C93.92 Monocytic leukemia, unspecified, not having achieved remission Monocytic leukemia, unspecified in relapse C93.Z0 Other monocytic leukemia, not having achieved remission C93.Z1 Other monocytic leukemia, in remission C93.Z2 Other monocytic leukemia, in relapse C94.00 C94.02 Acute erythroid leukemia, not having achieved remission Acute erythroid leukemia, in relapse C94.20 C94.22 Acute megakaryoblastic leukemia not having achieved remission Acute megakaryoblastic leukemia, in relapse C94.30 C94.32 Mast cell leukemia not having achieved remission Mast cell leukemia, in relapse C94.40 C94.42 Acute panmyelosis with myelofibrosis not having achieved remission Acute panmyelosis with myelofibrosis, in relapse C94.6 Myelodysplastic disease, not classified C94.80 C94.82 Other specified leukemias not having achieved remission Other specified leukemias, in relapse

22 C95.00 C95.02 Acute leukemia of unspecified cell type not having achieved remission Acute leukemia of unspecified cell type, in relapse C95.10 C95.12 Chronic leukemia of unspecified cell type not having achieved remission Chronic leukemia of unspecified cell type, in relapse C95.90 C95.92 Leukemia, unspecified not having achieved remission Leukemia, unspecified, in relapse C96.0 Multifocal and multisystemic (disseminated) Langerhanscell histiocytosis C96.2 Malignant mast cell tumor C96.4 Sarcoma of dendritic cells (accessory cells) C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified C96.A Histiocytic sarcoma C96.Z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue D00.01 D00.08 Carcinoma in situ of labial mucosa and vermilion border Carcinoma in situ of pharynx D00.1 Carcinoma in situ of esophagus D00.2 Carcinoma in situ of stomach D01.0 D01.3 Carcinoma in situ of colon Carcinoma in situ of anus and anal canal D01.49 Carcinoma in situ of other parts of intestine D01.5 Carcinoma in situ of liver, gallbladder and bile ducts D01.7 Carcinoma in situ of other specified digestive organs D01.9 Carcinoma in situ of digestive organ, unspecified D02.0 Carcinoma in situ of larynx D02.1 Carcinoma in situ of trachea D02.21 Carcinoma in situ of right bronchus and lung D02.22 Carcinoma in situ of left bronchus and lung D02.3 Carcinoma in situ of other parts of respiratory system D02.4 Carcinoma in situ of respiratory system, unspecified D03.0 Melanoma in situ of lip D03.11 Melanoma in situ of right eyelid, including canthus D03.12 Melanoma in situ of left eyelid, including canthus D03.21 Melanoma in situ of right ear and external auricular canal D03.22 Melanoma in situ of left ear and external auricular canal D03.30 Melanoma in situ of unspecified part of face D03.39 Melanoma in situ of other parts of face D03.4 Melanoma in situ of scalp and neck D03.51 Melanoma in situ of anal skin D03.52 Melanoma in situ of breast (skin) (soft tissue) D03.59 Melanoma in situ of other part of trunk D03.61 Melanoma in situ of right upper limb, including shoulder D03.62 Melanoma in situ of left upper limb, including shoulder

23 D03.71 Melanoma in situ of right lower limb, including hip D03.72 Melanoma in situ of left lower limb, including hip D03.8 Melanoma in situ of other sites D03.9 Melanoma in situ, unspecified D04.0 Carcinoma in situ of skin of lip D04.11 Carcinoma in situ of skin of right eyelid, including canthus D04.12 Carcinoma in situ of skin of left eyelid, including canthus D04.21 Carcinoma in situ of skin of right ear and external auricular canal D04.22 Carcinoma in situ of skin of left ear and external auricular canal D04.39 Carcinoma in situ of skin of other parts of face D04.4 Carcinoma in situ of skin of scalp and neck D04.5 Carcinoma in situ of skin of trunk D04.61 Carcinoma in situ of skin of right upper limb, including shoulder D04.62 Carcinoma in situ of skin of left upper limb, including shoulder D04.71 Carcinoma in situ of skin of right lower limb, including hip D04.72 Carcinoma in situ of skin of left lower limb, including hip D04.8 Carcinoma in situ of skin of other sites D04.9 Carcinoma in situ of skin, unspecified D05.01 Lobular carcinoma in situ of right breast D05.02 Lobular carcinoma in situ of left breast D05.11 Intraductal carcinoma in situ of right breast D05.12 Intraductal carcinoma in situ of left breast D05.81 Other specified type of carcinoma in situ of right breast D05.82 Other specified type of carcinoma in situ of left breast D05.91 Unspecified type of carcinoma in situ of right breast D05.92 Unspecified type of carcinoma in situ of left breast D06.0 Carcinoma in situ of endocervix D06.1 Carcinoma in situ of exocervix D06.7 Carcinoma in situ of other parts of cervix D07.0 D07.2 Carcinoma in situ of endometrium Carcinoma in situ of vagina D07.30 Carcinoma in situ of unspecified female genital organs D07.39 Carcinoma in situ of other female genital organs D07.4 Carcinoma in situ of penis D07.5 Carcinoma in situ of prostate D07.61 Carcinoma in situ of scrotum D07.69 Carcinoma in situ of other male genital organs D09.0 Carcinoma in situ of bladder D09.19 Carcinoma in situ of other urinary organs D09.21 Carcinoma in situ of right eye D09.22 Carcinoma in situ of left eye D09.3 Carcinoma in situ of thyroid and other endocrine glands

24 D09.8 Carcinoma in situ of other specified sites D09.9 Carcinoma in situ, unspecified D10.0 D10.2 Benign neoplasm of lip Benign neoplasm of floor of mouth D10.39 Benign neoplasm of other parts of mouth D10.4 D10.7 Benign neoplasm of tonsil Benign neoplasm of hypopharynx D10.9 Benign neoplasm of pharynx, unspecified D11.0 Benign neoplasm of parotid gland D11.7 Benign neoplasm of other major salivary glands D12.0 D12.5 Benign neoplasm of cecum Benign neoplasm of sigmoid colon D12.7 D12.9 Benign neoplasm of rectosigmoid junction Benign neoplasm of anus and anal canal D13.0 D13.2 Benign neoplasm of esophagus Benign neoplasm of duodenum D13.39 Benign neoplasm of other parts of small intestine D13.4 D13.7 Benign neoplasm of liver Benign neoplasm of endocrine pancreas D13.9 Benign neoplasm of illdefined sites within the digestive system D14.0 D14.2 Benign neoplasm of middle ear, nasal cavity and accessory sinuses Benign neoplasm of trachea D14.31 Benign neoplasm of right bronchus and lung D14.32 Benign neoplasm of left bronchus and lung D14.4 Benign neoplasm of respiratory system, unspecified D15.0 D15.2 Benign neoplasm of thymus Benign neoplasm of mediastinum D15.7 Benign neoplasm of other specified intrathoracic organs D15.9 Benign neoplasm of intrathoracic organ, unspecified D16.01 Benign neoplasm of scapula and long bones of right upper limb D16.02 Benign neoplasm of scapula and long bones of left upper limb D16.11 Benign neoplasm of short bones of right upper limb D16.12 Benign neoplasm of short bones of left upper limb D16.21 Benign neoplasm of long bones of right lower limb D16.22 Benign neoplasm of long bones of left lower limb D16.31 Benign neoplasm of short bones of right lower limb D16.32 Benign neoplasm of short bones of left lower limb D16.4 D16.9 Benign neoplasm of bones of skull and face Benign neoplasm of bone and articular cartilage, unspecified D17.0 Benign lipomatous neoplasm of skin and subcutaneous tissue of head, face and neck D17.1 Benign lipomatous neoplasm of skin and subcutaneous tissue of trunk

25 D17.21 D17.24 Benign lipomatous neoplasm of skin and subcutaneous tissue of right arm Benign lipomatous neoplasm of skin and subcutaneous tissue of left leg D17.39 Benign lipomatous neoplasm of skin and subcutaneous tissue of other sites D17.4 D17.6 Benign lipomatous neoplasm of intrathoracic organs Benign lipomatous neoplasm of spermatic cord D17.71 Benign lipomatous neoplasm of kidney D17.72 Benign lipomatous neoplasm of other genitourinary organ D17.79 Benign lipomatous neoplasm of other sites D17.9 Benign lipomatous neoplasm, unspecified D18.00 D18.03 Hemangioma unspecified site Hemangioma of intraabdominal structures D18.09 Hemangioma of other sites D18.1 Lymphangioma, any site D19.0 Benign neoplasm of mesothelial tissue of pleura D19.1 Benign neoplasm of mesothelial tissue of peritoneum D19.7 Benign neoplasm of mesothelial tissue of other sites D19.9 Benign neoplasm of mesothelial tissue, unspecified D20.0 Benign neoplasm of soft tissue of retroperitoneum D20.1 Benign neoplasm of soft tissue of peritoneum D21.0 Benign neoplasm of connective and other soft tissue of head, face and neck D21.11 Benign neoplasm of connective and other soft tissue of right upper limb, including shoulder D21.12 Benign neoplasm of connective and other soft tissue of left upper limb, including shoulder D21.21 Benign neoplasm of connective and other soft tissue of right lower limb, including hip D21.22 Benign neoplasm of connective and other soft tissue of left lower limb, including hip D21.3 D21.6 Benign neoplasm of connective and other soft tissue of thorax Benign neoplasm of connective and other soft tissue of trunk, unspecified D21.9 Benign neoplasm of connective and other soft tissue, unspecified D22.0 Melanocytic nevi of lip D22.11 Melanocytic nevi of right eyelid, including canthus D22.12 Melanocytic nevi of left eyelid, including canthus D22.21 Melanocytic nevi of right ear and external auricular canal D22.22 Melanocytic nevi of left ear and external auricular canal D22.39 Melanocytic nevi of other parts of face D22.4 Melanocytic nevi of scalp and neck D22.5 Melanocytic nevi of trunk D22.61 Melanocytic nevi of right upper limb, including shoulder D22.62 Melanocytic nevi of left upper limb, including shoulder D22.71 Melanocytic nevi of right lower limb, including hip D22.72 Melanocytic nevi of left lower limb, including hip

26 D22.9 Melanocytic nevi, unspecified D23.0 Other benign neoplasm of skin of lip D23.11 Other benign neoplasm of skin of right eyelid, including canthus D23.12 Other benign neoplasm of skin of left eyelid, including canthus D23.21 Other benign neoplasm of skin of right ear and external auricular canal D23.22 Other benign neoplasm of skin of left ear and external auricular canal D23.39 Other benign neoplasm of skin of other parts of face D23.4 Other benign neoplasm of skin of scalp and neck D23.5 Other benign neoplasm of skin of trunk D23.61 Other benign neoplasm of skin of right upper limb, including shoulder D23.62 Other benign neoplasm of skin of left upper limb, including shoulder D23.71 Other benign neoplasm of skin of right lower limb, including hip D23.72 Other benign neoplasm of skin of left lower limb, including hip D23.9 Other benign neoplasm of skin, unspecified D24.1 Benign neoplasm of right breast D24.2 Benign neoplasm of left breast D25.0 D25.2 Submucous leiomyoma of uterus Subserosal leiomyoma of uterus D25.9 Leiomyoma of uterus, unspecified D26.0 Other benign neoplasm of cervix uteri D26.1 Other benign neoplasm of corpus uteri D26.7 Other benign neoplasm of other parts of uterus D26.9 Other benign neoplasm of uterus, unspecified D27.0 Benign neoplasm of right ovary D27.1 Benign neoplasm of left ovary D28.0 D28.2 Benign neoplasm of vulva Benign neoplasm of uterine tubes and ligaments D28.7 Benign neoplasm of other specified female genital organs D28.9 Benign neoplasm of female genital organ, unspecified D29.0 Benign neoplasm of penis D29.1 Benign neoplasm of prostate D29.21 Benign neoplasm of right testis D29.22 Benign neoplasm of left testis D29.31 Benign neoplasm of right epididymis D29.32 Benign neoplasm of left epididymis D29.4 Benign neoplasm of scrotum D29.8 Benign neoplasm of other specified male genital organs D29.9 Benign neoplasm of male genital organ, unspecified D30.01 Benign neoplasm of right kidney D30.02 Benign neoplasm of left kidney D30.11 Benign neoplasm of right renal pelvis D30.12 Benign neoplasm of left renal pelvis

27 D30.21 Benign neoplasm of right ureter D30.22 Benign neoplasm of left ureter D30.3 Benign neoplasm of bladder D30.4 Benign neoplasm of urethra D30.8 Benign neoplasm of other specified urinary organs D30.9 Benign neoplasm of urinary organ, unspecified D31.01 Benign neoplasm of right conjunctiva D31.02 Benign neoplasm of left conjunctiva D31.11 Benign neoplasm of right cornea D31.12 Benign neoplasm of left cornea D31.21 Benign neoplasm of right retina D31.22 Benign neoplasm of left retina D31.31 Benign neoplasm of right choroid D31.32 Benign neoplasm of left choroid D31.41 Benign neoplasm of right ciliary body D31.42 Benign neoplasm of left ciliary body D31.51 Benign neoplasm of right lacrimal gland and duct D31.52 Benign neoplasm of left lacrimal gland and duct D31.61 Benign neoplasm of unspecified site of right orbit D31.62 Benign neoplasm of unspecified site of left orbit D31.91 Benign neoplasm of unspecified part of right eye D31.92 Benign neoplasm of unspecified part of left eye D32.0 Benign neoplasm of cerebral meninges D32.1 Benign neoplasm of spinal meninges D33.0 D33.4 Benign neoplasm of brain, supratentorial Benign neoplasm of spinal cord D33.7 Benign neoplasm of other specified parts of central nervous system D33.9 Benign neoplasm of central nervous system, unspecified D34 Benign neoplasm of thyroid gland D35.01 Benign neoplasm of right adrenal gland D35.02 Benign neoplasm of left adrenal gland D35.1 D35.7 Benign neoplasm of parathyroid gland Benign neoplasm of other specified endocrine glands D35.9 Benign neoplasm of endocrine gland, unspecified D36.0 Benign neoplasm of lymph nodes D36.11 D36.16 Benign neoplasm of peripheral nerves and autonomic nervous system of face, head, and neck Benign neoplasm of peripheral nerves and autonomic nervous system of pelvis D36.7 Benign neoplasm of other specified sites D36.9 Benign neoplasm, unspecified site D37.01 Neoplasm of uncertain behavior of lip D37.02 Neoplasm of uncertain behavior of tongue

28 D D Neoplasm of uncertain behavior of the parotid salivary glands Neoplasm of uncertain behavior of the submandibular salivary glands D Neoplasm of uncertain behavior of the major salivary glands, unspecified D37.04 Neoplasm of uncertain behavior of the minor salivary glands D37.05 Neoplasm of uncertain behavior of pharynx D37.09 Neoplasm of uncertain behavior of other specified sites of the oral cavity D37.1 D37.6 Neoplasm of uncertain behavior of stomach Neoplasm of uncertain behavior of liver, gallbladder and bile ducts D37.8 Neoplasm of uncertain behavior of other specified digestive organs D38.0 D38.5 Neoplasm of uncertain behavior of larynx Neoplasm of uncertain behavior of other respiratory organs D39.0 Neoplasm of uncertain behavior of uterus D39.11 Neoplasm of uncertain behavior of right ovary D39.12 Neoplasm of uncertain behavior of left ovary D39.2 Neoplasm of uncertain behavior of placenta D39.8 Neoplasm of uncertain behavior of other specified female genital organs D3A.010 Benign carcinoid tumor of the duodenum D3A.011 Benign carcinoid tumor of the jejunum D3A.012 Benign carcinoid tumor of the ileum D3A.019 Benign carcinoid tumor of the small intestine, unspecified portion D3A.020 Benign carcinoid tumor of the appendix D3A.021 Benign carcinoid tumor of the cecum D3A.022 Benign carcinoid tumor of the ascending colon D3A.023 Benign carcinoid tumor of the transverse colon D3A.024 Benign carcinoid tumor of the descending colon D3A.025 Benign carcinoid tumor of the sigmoid colon D3A.026 Benign carcinoid tumor of the rectum D3A.029 Benign carcinoid tumor of the large intestine, unspecified portion D3A.090 Benign carcinoid tumor of the bronchus and lung D3A.091 Benign carcinoid tumor of the thymus D3A.092 Benign carcinoid tumor of the stomach D3A.093 Benign carcinoid tumor of the kidney D3A.094 Benign carcinoid tumor of the foregut NOS D3A.095 Benign carcinoid tumor of the midgut NOS D3A.096 Benign carcinoid tumor of the hindgut NOS D3A.098 Benign carcinoid tumors of other sites D3A.8 Other benign neuroendocrine tumors D40.0 Neoplasm of uncertain behavior of prostate D40.11 Neoplasm of uncertain behavior of right testis D40.12 Neoplasm of uncertain behavior of left testis D41.01 Neoplasm of uncertain behavior of right kidney D41.02 Neoplasm of uncertain behavior of left kidney

29 D41.11 Neoplasm of uncertain behavior of right renal pelvis D41.12 Neoplasm of uncertain behavior of left renal pelvis D41.21 Neoplasm of uncertain behavior of right ureter D41.22 Neoplasm of uncertain behavior of left ureter D41.3 Neoplasm of uncertain behavior of urethra D41.4 Neoplasm of uncertain behavior of bladder D41.8 Neoplasm of uncertain behavior of other specified urinary organs D41.9 Neoplasm of uncertain behavior of unspecified urinary organ D42.0 Neoplasm of uncertain behavior of cerebral meninges D42.1 Neoplasm of uncertain behavior of spinal meninges D43.0 Neoplasm of uncertain behavior of brain, supratentorial D43.1 Neoplasm of uncertain behavior of brain, infratentorial D43.3 Neoplasm of uncertain behavior of cranial nerves D43.4 Neoplasm of uncertain behavior of spinal cord D43.8 Neoplasm of uncertain behavior of other specified parts of central nervous system D44.0 Neoplasm of uncertain behavior of thyroid gland D44.11 Neoplasm of uncertain behavior of right adrenal gland D44.12 Neoplasm of uncertain behavior of left adrenal gland D44.2 D44.7 Neoplasm of uncertain behavior of parathyroid gland Neoplasm of uncertain behavior of aortic body and other paraganglia D44.9 Neoplasm of uncertain behavior of unspecified endocrine gland D45 Polycythemia vera D46.0 Refractory anemia without ring sideroblasts, so stated D46.1 Refractory anemia with ring sideroblasts D46.20 D46.22 Refractory anemia with excess of blasts, unspecified 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.Z Other myelodysplastic syndromes D47.0 D47.3 Histiocytic and mast cell tumors of uncertain behavior Essential (hemorrhagic) thrombocythemia D47.Z9 Other specified neoplasms of uncertain behavior of lymphoid, hematopoietic and related tissue D48.0 D48.5 Neoplasm of uncertain behavior of bone and articular cartilage Neoplasm of uncertain behavior of skin D48.61 Neoplasm of uncertain behavior of right breast D48.62 Neoplasm of uncertain behavior of left breast D48.7 Neoplasm of uncertain behavior of other specified sites D48.9 Neoplasm of uncertain behavior, unspecified D49.0 D49.7 Neoplasm of unspecified behavior of digestive system Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system

30 D49.81 Neoplasm of unspecified behavior of retina and choroid D49.89 Neoplasm of unspecified behavior of other specified sites D49.9 Neoplasm of unspecified behavior of unspecified site D89.2 Hypergammaglobulinemia, unspecified E08.43 Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy E09.43 Drug or chemical induced diabetes mellitus with neurological complications with diabetic autonomic (poly)neuropathy E10.43 Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathy E11.43 Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathy E13.43 Other specified diabetes mellitus with diabetic autonomic (poly)neuropathy E34.0 Carcinoid syndrome G71.0 Muscular dystrophy G71.11 G71.14 Myotonic muscular dystrophy Drug induced myotonia G71.19 Other specified myotonic disorders G71.2 Congenital myopathies G71.3 Mitochondrial myopathy, not elsewhere classified G71.8 Other primary disorders of muscles G71.9 Primary disorder of muscle, unspecified G72.0 G72.3 Druginduced myopathy Periodic paralysis G72.81 Critical illness myopathy G72.89 Other specified myopathies G72.9 Myopathy, unspecified G73.7 Myopathy in diseases classified elsewhere G93.82 Brain death G93.89 Other specified disorders of brain I I Atherosclerosis of native arteries of right leg with ulceration of thigh Atherosclerosis of native arteries of right leg with ulceration of other part of foot I Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg I Atherosclerosis of native arteries of right leg with ulceration of unspecified site I I Atherosclerosis of native arteries of left leg with ulceration of thigh Atherosclerosis of native arteries of left leg with ulceration of other part of foot I Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg I Atherosclerosis of native arteries of left leg with ulceration of unspecified site Atherosclerosis of unspecified type of bypass graft(s) of the right leg with I ulceration of thigh Atherosclerosis of unspecified type of bypass graft(s) of the I right leg with ulceration of other part of foot I Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of other part of lower leg

31 I I I I I I I I I I I I I I I I I I I I I I I I I Atherosclerosis of unspecified type of bypass graft(s) of the right leg with ulceration of unspecified site Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of thigh Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of foot Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of other part of lower leg Atherosclerosis of unspecified type of bypass graft(s) of the left leg with ulceration of unspecified site Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of thigh Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of foot Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of other part of lower leg Atherosclerosis of autologous vein bypass graft(s) of the right leg with ulceration of unspecified site Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of thigh Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of foot Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of other part of lower leg Atherosclerosis of autologous vein bypass graft(s) of the left leg with ulceration of unspecified site Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of thigh Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of foot Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of other part of lower leg Atherosclerosis of nonautologous biological bypass graft(s) of the right leg with ulceration of unspecified site Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of thigh Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of foot Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of other part of lower leg Atherosclerosis of nonautologous biological bypass graft(s) of the left leg with ulceration of unspecified site Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of thigh Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of foot Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of other part of lower leg Atherosclerosis of nonbiological bypass graft(s) of the right leg with ulceration of unspecified site

32 I I I I I I I I I I I I Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of thigh Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of foot Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of other part of lower leg Atherosclerosis of nonbiological bypass graft(s) of the left leg with ulceration of unspecified site Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of thigh Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of foot Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of other part of lower leg Atherosclerosis of other type of bypass graft(s) of the right leg with ulceration of unspecified site Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of thigh Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of foot Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of other part of lower leg Atherosclerosis of other type of bypass graft(s) of the left leg with ulceration of unspecified site I88.0 Nonspecific mesenteric lymphadenitis I88.1 Chronic lymphadenitis, except mesenteric I88.8 Other nonspecific lymphadenitis I88.9 Nonspecific lymphadenitis, unspecified J20.4 Acute bronchitis due to parainfluenza virus J86.0 Pyothorax with fistula J91.8 Pleural effusion in other conditions classified elsewhere K20.0 Eosinophilic esophagitis K20.8 Other esophagitis K20.9 Esophagitis, unspecified K21.0 Gastroesophageal reflux disease with esophagitis K21.9 Gastroesophageal reflux disease without esophagitis K22.0 Achalasia of cardia K22.10 Ulcer of esophagus without bleeding K22.11 Ulcer of esophagus with bleeding K22.2 K22.6 Esophageal obstruction Gastroesophageal lacerationhemorrhage syndrome K22.70 Barrett's esophagus without dysplasia K Barrett's esophagus with low grade dysplasia K Barrett's esophagus with high grade dysplasia K22.8 Other specified diseases of esophagus K22.9 Disease of esophagus, unspecified

33 K23 Disorders of esophagus in diseases classified elsewhere K25.0 K25.7 Acute gastric ulcer with hemorrhage Chronic gastric ulcer without hemorrhage or perforation K25.9 Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation K26.0 K26.5 Acute duodenal ulcer with hemorrhage Chronic or unspecified duodenal ulcer with perforation K26.7 Chronic duodenal ulcer without hemorrhage or perforation K26.9 Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation K27.0 K27.7 Acute peptic ulcer, site unspecified, with hemorrhage Chronic peptic ulcer, site unspecified, without hemorrhage or perforation K27.9 Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation K28.0 K28.7 Acute gastrojejunal ulcer with hemorrhage Chronic gastrojejunal ulcer without hemorrhage or perforation K28.9 Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation K29.00 Acute gastritis without bleeding K29.01 Acute gastritis with bleeding K29.20 Alcoholic gastritis without bleeding K29.21 Alcoholic gastritis with bleeding K29.30 Chronic superficial gastritis without bleeding K29.31 Chronic superficial gastritis with bleeding K29.40 Chronic atrophic gastritis without bleeding K29.41 Chronic atrophic gastritis with bleeding K29.50 Unspecified chronic gastritis without bleeding K29.51 Unspecified chronic gastritis with bleeding K29.60 Other gastritis without bleeding K29.61 Other gastritis with bleeding K29.70 Gastritis, unspecified, without bleeding K29.71 Gastritis, unspecified, with bleeding K29.80 Duodenitis without bleeding K29.81 Duodenitis with bleeding K29.90 Gastroduodenitis, unspecified, without bleeding K29.91 Gastroduodenitis, unspecified, with bleeding K30 Functional dyspepsia K31.0 K31.7 Acute dilatation of stomach Polyp of stomach and duodenum K Angiodysplasia of stomach and duodenum with bleeding K Angiodysplasia of stomach and duodenum without bleeding K31.82 K31.84 Dieulafoy lesion (hemorrhagic) of stomach and duodenum Gastroparesis K31.89 Other diseases of stomach and duodenum

34 K31.9 Disease of stomach and duodenum, unspecified K35.2 Acute appendicitis with generalized peritonitis K35.3 Acute appendicitis with localized peritonitis K35.80 Unspecified acute appendicitis K35.89 Other acute appendicitis K36 Other appendicitis K37 Unspecified appendicitis K38.0 K38.3 Hyperplasia of appendix Fistula of appendix K38.8 Other specified diseases of appendix K40.00 Bilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent K40.01 Bilateral inguinal hernia, with obstruction, without gangrene, recurrent K40.10 Bilateral inguinal hernia, with gangrene, not specified as recurrent K40.11 Bilateral inguinal hernia, with gangrene, recurrent K40.20 Bilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent K40.21 Bilateral inguinal hernia, without obstruction or gangrene, recurrent K40.30 Unilateral inguinal hernia, with obstruction, without gangrene, not specified as recurrent K40.31 Unilateral inguinal hernia, with obstruction, without gangrene, recurrent K40.40 Unilateral inguinal hernia, with gangrene, not specified as recurrent K40.41 Unilateral inguinal hernia, with gangrene, recurrent K40.90 Unilateral inguinal hernia, without obstruction or gangrene, not specified as recurrent K40.91 Unilateral inguinal hernia, without obstruction or gangrene, recurrent K41.00 Bilateral femoral hernia, with obstruction, without gangrene, not specified as recurrent K41.01 Bilateral femoral hernia, with obstruction, without gangrene, recurrent K41.10 Bilateral femoral hernia, with gangrene, not specified as recurrent K41.11 Bilateral femoral hernia, with gangrene, recurrent K41.20 Bilateral femoral hernia, without obstruction or gangrene, not specified as recurrent K41.21 Bilateral femoral hernia, without obstruction or gangrene, recurrent K41.30 Unilateral femoral hernia, with obstruction, without gangrene, not specified as recurrent K41.31 Unilateral femoral hernia, with obstruction, without gangrene, recurrent K41.40 Unilateral femoral hernia, with gangrene, not specified as recurrent K41.41 Unilateral femoral hernia, with gangrene, recurrent K41.90 Unilateral femoral hernia, without obstruction or gangrene, not specified as recurrent K41.91 Unilateral femoral hernia, without obstruction or gangrene, recurrent K42.0 Umbilical hernia with obstruction, without gangrene

35 K42.1 Umbilical hernia with gangrene K42.9 Umbilical hernia without obstruction or gangrene K43.0 K43.7 Incisional hernia with obstruction, without gangrene Other and unspecified ventral hernia with gangrene K43.9 Ventral hernia without obstruction or gangrene K44.0 Diaphragmatic hernia with obstruction, without gangrene K44.1 Diaphragmatic hernia with gangrene K44.9 Diaphragmatic hernia without obstruction or gangrene K45.0 Other specified abdominal hernia with obstruction, without gangrene K45.1 Other specified abdominal hernia with gangrene K45.8 Other specified abdominal hernia without obstruction or gangrene K46.0 Unspecified abdominal hernia with obstruction, without gangrene K46.1 Unspecified abdominal hernia with gangrene K46.9 Unspecified abdominal hernia without obstruction or gangrene K50.00 Crohn's disease of small intestine without complications K K Crohn's disease of small intestine with rectal bleeding Crohn's disease of small intestine with abscess K Crohn's disease of small intestine with other complication K50.10 Crohn's disease of large intestine without complications K K Crohn's disease of large intestine with rectal bleeding Crohn's disease of large intestine with abscess K Crohn's disease of large intestine with other complication K50.80 Crohn's disease of both small and large intestine without complications K K Crohn's disease of both small and large intestine with rectal bleeding Crohn's disease of both small and large intestine with abscess K Crohn's disease of both small and large intestine with other complication K50.90 Crohn's disease, unspecified, without complications K K Crohn's disease, unspecified, with rectal bleeding Crohn's disease, unspecified, with abscess K Crohn's disease, unspecified, with other complication K51.00 Ulcerative (chronic) pancolitis without complications K K Ulcerative (chronic) pancolitis with rectal bleeding Ulcerative (chronic) pancolitis with abscess K Ulcerative (chronic) pancolitis with other complication K51.20 Ulcerative (chronic) proctitis without complications K K Ulcerative (chronic) proctitis with rectal bleeding Ulcerative (chronic) proctitis with abscess K Ulcerative (chronic) proctitis with other complication K51.30 Ulcerative (chronic) rectosigmoiditis without complications K K Ulcerative (chronic) rectosigmoiditis with rectal bleeding Ulcerative (chronic) rectosigmoiditis with abscess K Ulcerative (chronic) rectosigmoiditis with other complication K51.40 Inflammatory polyps of colon without complications

36 K K Inflammatory polyps of colon with rectal bleeding Inflammatory polyps of colon with abscess K Inflammatory polyps of colon with other complication K51.50 Left sided colitis without complications K K Left sided colitis with rectal bleeding Left sided colitis with abscess K Left sided colitis with other complication K51.80 Other ulcerative colitis without complications K K Other ulcerative colitis with rectal bleeding Other ulcerative colitis with abscess K Other ulcerative colitis with other complication K51.90 Ulcerative colitis, unspecified, without complications K K Ulcerative colitis, unspecified with rectal bleeding Ulcerative colitis, unspecified with abscess K Ulcerative colitis, unspecified with other complication K52.0 Gastroenteritis and colitis due to radiation K52.1 Toxic gastroenteritis and colitis K52.2 Allergic and dietetic gastroenteritis and colitis K52.81 Eosinophilic gastritis or gastroenteritis K52.82 Eosinophilic colitis K52.89 Other specified noninfective gastroenteritis and colitis K55.0 Acute vascular disorders of intestine K55.1 Chronic vascular disorders of intestine K55.20 Angiodysplasia of colon without hemorrhage K55.21 Angiodysplasia of colon with hemorrhage K55.8 Other vascular disorders of intestine K56.0 K56.3 Paralytic ileus Gallstone ileus K56.49 Other impaction of intestine K56.5 Intestinal adhesions [bands] with obstruction (postprocedural) (postinfection) K56.60 Unspecified intestinal obstruction K56.69 Other intestinal obstruction K56.7 Ileus, unspecified K57.00 Diverticulitis of small intestine with perforation and abscess without bleeding K57.01 Diverticulitis of small intestine with perforation and abscess with bleeding K57.10 K57.13 Diverticulosis of small intestine without perforation or abscess without bleeding Diverticulitis of small intestine without perforation or abscess with bleeding K57.20 Diverticulitis of large intestine with perforation and abscess without bleeding K57.21 Diverticulitis of large intestine with perforation and abscess with bleeding K57.30 K57.33 Diverticulosis of large intestine without perforation or abscess without bleeding Diverticulitis of large intestine without perforation or abscess with bleeding K57.40 Diverticulitis of both small and large intestine with perforation and abscess without bleeding

37 K57.41 K57.50 K57.53 K57.80 K57.81 K57.90 K57.93 Diverticulitis of both small and large intestine with perforation and abscess with bleeding Diverticulosis of both small and large intestine without perforation or abscess without bleeding Diverticulitis of both small and large intestine without perforation or abscess with bleeding Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding Diverticulitis of intestine, part unspecified, with perforation and abscess with bleeding Diverticulosis of intestine, part unspecified, without perforation or abscess without bleeding Diverticulitis of intestine, part unspecified, without perforation or abscess with bleeding K58.0 Irritable bowel syndrome with diarrhea K58.9 Irritable bowel syndrome without diarrhea K59.00 K59.02 Constipation, unspecified Outlet dysfunction constipation K59.09 Other constipation K59.1 K59.4 Functional diarrhea Anal spasm K59.8 Other specified functional intestinal disorders K59.9 Functional intestinal disorder, unspecified K60.0 K60.5 Acute anal fissure Anorectal fistula K61.0 K61.4 Anal abscess Intrasphincteric abscess K62.0 K62.7 Anal polyp Radiation proctitis K62.81 Anal sphincter tear (healed) (nontraumatic) (old) K62.82 Dysplasia of anus K62.89 Other specified diseases of anus and rectum K63.1 K63.5 Perforation of intestine (nontraumatic) Polyp of colon K63.81 Dieulafoy lesion of intestine K63.89 Other specified diseases of intestine K63.9 Disease of intestine, unspecified K65.0 K65.4 Generalized (acute) peritonitis Sclerosing mesenteritis K65.8 Other peritonitis K65.9 Peritonitis, unspecified K66.0 Peritoneal adhesions (postprocedural) (postinfection) K66.1 Hemoperitoneum K66.8 Other specified disorders of peritoneum K67 Disorders of peritoneum in infectious diseases classified elsewhere

38 K68.12 Psoas muscle abscess K68.19 Other retroperitoneal abscess K68.9 Other disorders of retroperitoneum K70.0 Alcoholic fatty liver K70.10 Alcoholic hepatitis without ascites K70.11 Alcoholic hepatitis with ascites K70.2 Alcoholic fibrosis and sclerosis of liver K70.30 Alcoholic cirrhosis of liver without ascites K70.31 Alcoholic cirrhosis of liver with ascites K70.40 Alcoholic hepatic failure without coma K70.41 Alcoholic hepatic failure with coma K70.9 Alcoholic liver disease, unspecified K71.0 Toxic liver disease with cholestasis K71.10 Toxic liver disease with hepatic necrosis, without coma K71.11 Toxic liver disease with hepatic necrosis, with coma K71.2 K71.4 Toxic liver disease with acute hepatitis Toxic liver disease with chronic lobular hepatitis K71.50 Toxic liver disease with chronic active hepatitis without ascites K71.51 Toxic liver disease with chronic active hepatitis with ascites K71.6 K71.8 Toxic liver disease with hepatitis, not elsewhere classified Toxic liver disease with other disorders of liver K72.00 Acute and subacute hepatic failure without coma K72.01 Acute and subacute hepatic failure with coma K72.10 Chronic hepatic failure without coma K72.11 Chronic hepatic failure with coma K72.90 Hepatic failure, unspecified without coma K72.91 Hepatic failure, unspecified with coma K73.0 K73.2 Chronic persistent hepatitis, not elsewhere classified Chronic active hepatitis, not elsewhere classified K73.8 Other chronic hepatitis, not elsewhere classified K73.9 Chronic hepatitis, unspecified K74.0 K74.5 Hepatic fibrosis Biliary cirrhosis, unspecified K74.60 Unspecified cirrhosis of liver K74.69 Other cirrhosis of liver K75.0 K75.4 Abscess of liver Autoimmune hepatitis K75.81 Nonalcoholic steatohepatitis (NASH) K75.89 Other specified inflammatory liver diseases K76.0 K76.7 Fatty (change of) liver, not elsewhere classified Hepatorenal syndrome K76.81 Hepatopulmonary syndrome

39 K76.89 Other specified diseases of liver K76.9 Liver disease, unspecified K77 Liver disorders in diseases classified elsewhere K80.00 Calculus of gallbladder with acute cholecystitis without obstruction K80.01 Calculus of gallbladder with acute cholecystitis with obstruction K80.10 K80.13 Calculus of gallbladder with chronic cholecystitis without obstruction Calculus of gallbladder with acute and chronic cholecystitis with obstruction K80.18 Calculus of gallbladder with other cholecystitis without obstruction K80.19 Calculus of gallbladder with other cholecystitis with obstruction K80.20 Calculus of gallbladder without cholecystitis without obstruction K80.21 Calculus of gallbladder without cholecystitis with obstruction K80.30 K80.37 Calculus of bile duct with cholangitis, unspecified, without obstruction Calculus of bile duct with acute and chronic cholangitis with obstruction K80.40 K80.47 Calculus of bile duct with cholecystitis, unspecified, without obstruction Calculus of bile duct with acute and chronic cholecystitis with obstruction K80.50 Calculus of bile duct without cholangitis or cholecystitis without obstruction K80.51 Calculus of bile duct without cholangitis or cholecystitis with obstruction Calculus of gallbladder and bile duct with cholecystitis, unspecified, without K80.60 obstruction Calculus of gallbladder and bile duct with acute and chronic K80.67 cholecystitis with obstruction K80.70 Calculus of gallbladder and bile duct without cholecystitis without obstruction K80.71 Calculus of gallbladder and bile duct without cholecystitis with obstruction K80.80 Other cholelithiasis without obstruction K80.81 Other cholelithiasis with obstruction K81.0 K81.2 Acute cholecystitis Acute cholecystitis with chronic cholecystitis K81.9 Cholecystitis, unspecified K82.0 K82.4 Obstruction of gallbladder Cholesterolosis of gallbladder K82.8 Other specified diseases of gallbladder K82.9 Disease of gallbladder, unspecified K83.0 K83.5 Cholangitis Biliary cyst K83.8 Other specified diseases of biliary tract K83.9 Disease of biliary tract, unspecified K85.0 K85.3 Idiopathic acute pancreatitis Drug induced acute pancreatitis K85.8 Other acute pancreatitis K86.0 K86.3 Alcoholinduced chronic pancreatitis Pseudocyst of pancreas K86.8 Other specified diseases of pancreas K86.9 Disease of pancreas, unspecified

40 K87 Disorders of gallbladder, biliary tract and pancreas in diseases classified elsewhere K90.0 Celiac disease K91.0 Vomiting following gastrointestinal surgery K91.1 Postgastric surgery syndromes K91.5 Postcholecystectomy syndrome K Pouchitis K Other complications of intestinal pouch K91.89 Other postprocedural complications and disorders of digestive system K92.0 K92.2 Hematemesis Gastrointestinal hemorrhage, unspecified K92.81 Gastrointestinal mucositis (ulcerative) K92.89 Other specified diseases of the digestive system K92.9 Disease of digestive system, unspecified K94.00 K94.03 Colostomy complication, unspecified Colostomy malfunction K94.09 K94.13 Other complications of colostomy Enterostomy malfunction K94.19 Other complications of enterostomy K94.20 K94.23 Gastrostomy complication, unspecified Gastrostomy malfunction K94.29 Other complications of gastrostomy K94.31 K94.33 Esophagostomy hemorrhage Esophagostomy malfunction K94.39 Other complications of esophagostomy L11.0 Acquired keratosis follicularis L11.1 Transient acantholytic dermatosis [Grover] L11.8 Other specified acantholytic disorders L28.0 Lichen simplex chronicus L28.1 Prurigo nodularis L30.0 Nummular dermatitis L30.2 Cutaneous autosensitization L30.8 Other specified dermatitis L44.2 Lichen striatus L44.3 Lichen ruber moniliformis L55.0 L55.2 Sunburn of first degree Sunburn of third degree L56.0 L56.3 Drug phototoxic response Solar urticaria L56.5 Disseminated superficial actinic porokeratosis (DSAP) L56.8 Other specified acute skin changes due to ultraviolet radiation L57.0 L57.2 Actinic keratosis Cutis rhomboidalis nuchae

41 L57.4 Cutis laxa senilis L57.5 Actinic granuloma L57.8 Other skin changes due to chronic exposure to nonionizing radiation L66.4 Folliculitis ulerythematosa reticulata L82.0 Inflamed seborrheic keratosis L82.1 Other seborrheic keratosis L83 Acanthosis nigricans L85.0 L85.2 Acquired ichthyosis Keratosis punctata (palmaris et plantaris) L85.8 Other specified epidermal thickening L86 Keratoderma in diseases classified elsewhere L87.0 L87.2 Keratosis follicularis et parafollicularis in cutem penetrans Elastosis perforans serpiginosa L87.8 Other transepidermal elimination disorders L L Pressure ulcer of right elbow, unstageable Pressure ulcer of right elbow, stage 4 L Pressure ulcer of right elbow, unspecified stage L L Pressure ulcer of left elbow, unstageable Pressure ulcer of left elbow, stage 4 L Pressure ulcer of left elbow, unspecified stage L L Pressure ulcer of right upper back, unstageable Pressure ulcer of right upper back, stage 4 L Pressure ulcer of right upper back, unspecified stage L L Pressure ulcer of left upper back, unstageable Pressure ulcer of left upper back, stage 4 L Pressure ulcer of left upper back, unspecified stage L L Pressure ulcer of right lower back, unstageable Pressure ulcer of right lower back, stage 4 L Pressure ulcer of right lower back, unspecified stage L L Pressure ulcer of left lower back, unstageable Pressure ulcer of left lower back, stage 4 L Pressure ulcer of left lower back, unspecified stage L L Pressure ulcer of sacral region, unstageable Pressure ulcer of sacral region, stage 4 L Pressure ulcer of sacral region, unspecified stage L L Pressure ulcer of right hip, unstageable Pressure ulcer of right hip, stage 4 L Pressure ulcer of right hip, unspecified stage L L Pressure ulcer of left hip, unstageable Pressure ulcer of left hip, stage 4 L Pressure ulcer of left hip, unspecified stage L L Pressure ulcer of right buttock, unstageable Pressure ulcer of right buttock, stage 4

42 L Pressure ulcer of right buttock, unspecified stage L L Pressure ulcer of left buttock, unstageable Pressure ulcer of left buttock, stage 4 L Pressure ulcer of left buttock, unspecified stage L89.40 L89.45 Pressure ulcer of contiguous site of back, buttock and hip, unspecified stage Pressure ulcer of contiguous site of back, buttock and hip, unstageable L L Pressure ulcer of right ankle, unstageable Pressure ulcer of right ankle, stage 4 L Pressure ulcer of right ankle, unspecified stage L L Pressure ulcer of left ankle, unstageable Pressure ulcer of left ankle, stage 4 L Pressure ulcer of left ankle, unspecified stage L L Pressure ulcer of right heel, unstageable Pressure ulcer of right heel, stage 4 L Pressure ulcer of right heel, unspecified stage L L Pressure ulcer of left heel, unstageable Pressure ulcer of left heel, stage 4 L Pressure ulcer of left heel, unspecified stage L L Pressure ulcer of head, unstageable Pressure ulcer of head, stage 4 L Pressure ulcer of head, unspecified stage L L Pressure ulcer of other site, unstageable Pressure ulcer of other site, stage 4 L Pressure ulcer of other site, unspecified stage L89.91 L89.94 Pressure ulcer of unspecified site, stage 1 Pressure ulcer of unspecified site, stage 4 L90.0 L90.6 Lichen sclerosus et atrophicus Striae atrophicae L90.8 Other atrophic disorders of skin L91.0 Hypertrophic scar L91.8 Other hypertrophic disorders of the skin L92.2 Granuloma faciale [eosinophilic granuloma of skin] L92.9 Granulomatous disorder of the skin and subcutaneous tissue, unspecified L94.0 Localized scleroderma [morphea] L94.1 Linear scleroderma L94.3 Sclerodactyly L94.8 Other specified localized connective tissue disorders L L Nonpressure chronic ulcer of right thigh limited to breakdown of skin Nonpressure chronic ulcer of right thigh with necrosis of bone L Nonpressure chronic ulcer of right thigh with unspecified severity L L Nonpressure chronic ulcer of left thigh limited to breakdown of skin Nonpressure chronic ulcer of left thigh with necrosis of bone L Nonpressure chronic ulcer of left thigh with unspecified severity

43 L L Nonpressure chronic ulcer of right calf limited to breakdown of skin Nonpressure chronic ulcer of right calf with necrosis of bone L Nonpressure chronic ulcer of right calf with unspecified severity L L Nonpressure chronic ulcer of left calf limited to breakdown of skin Nonpressure chronic ulcer of left calf with necrosis of bone L Nonpressure chronic ulcer of left calf with unspecified severity L L Nonpressure chronic ulcer of right ankle limited to breakdown of skin Nonpressure chronic ulcer of right ankle with necrosis of bone L Nonpressure chronic ulcer of right ankle with unspecified severity L L Nonpressure chronic ulcer of left ankle limited to breakdown of skin Nonpressure chronic ulcer of left ankle with necrosis of bone L Nonpressure chronic ulcer of left ankle with unspecified severity L L Nonpressure chronic ulcer of right heel and midfoot limited to breakdown of skin Nonpressure chronic ulcer of right heel and midfoot with necrosis of bone L Nonpressure chronic ulcer of right heel and midfoot with unspecified severity L L Nonpressure chronic ulcer of left heel and midfoot limited to breakdown of skin Nonpressure chronic ulcer of left heel and midfoot with necrosis of bone L Nonpressure chronic ulcer of left heel and midfoot with unspecified severity L L Nonpressure chronic ulcer of other part of right foot limited to breakdown of skin Nonpressure chronic ulcer of other part of right foot with necrosis of bone L Nonpressure chronic ulcer of other part of right foot with unspecified severity L L Nonpressure chronic ulcer of other part of left foot limited to breakdown of skin Nonpressure chronic ulcer of other part of left foot with necrosis of bone L Nonpressure chronic ulcer of other part of left foot with unspecified severity Nonpressure chronic ulcer of other part of right lower leg limited to breakdown L of skin Nonpressure chronic ulcer of other part of right lower leg with necrosis L of bone L Nonpressure chronic ulcer of other part of right lower leg with unspecified severity L L L L L L L L L Nonpressure chronic ulcer of other part of left lower leg limited to breakdown of skin Nonpressure chronic ulcer of other part of left lower leg with necrosis of bone Nonpressure chronic ulcer of other part of left lower leg with unspecified severity Nonpressure chronic ulcer of unspecified part of right lower leg limited to breakdown of skin Nonpressure chronic ulcer of unspecified part of right lower leg with necrosis of bone Nonpressure chronic ulcer of unspecified part of right lower leg with unspecified severity Nonpressure chronic ulcer of unspecified part of left lower leg limited to breakdown of skin Nonpressure chronic ulcer of unspecified part of left lower leg with necrosis of bone Nonpressure chronic ulcer of unspecified part of left lower leg with unspecified severity

44 L L Nonpressure chronic ulcer of buttock limited to breakdown of skin Nonpressure chronic ulcer of buttock with necrosis of bone L Nonpressure chronic ulcer of buttock with unspecified severity L L Nonpressure chronic ulcer of back limited to breakdown of skin Nonpressure chronic ulcer of back with necrosis of bone L Nonpressure chronic ulcer of back with unspecified severity L L Nonpressure chronic ulcer of skin of other sites limited to breakdown of skin Nonpressure chronic ulcer of skin of other sites with necrosis of bone L Nonpressure chronic ulcer of skin of other sites with unspecified severity L98.5 Mucinosis of the skin L98.6 Other infiltrative disorders of the skin and subcutaneous tissue L98.9 Disorder of the skin and subcutaneous tissue, unspecified L99 Other disorders of skin and subcutaneous tissue in diseases classified elsewhere M Rheumatoid myopathy with rheumatoid arthritis of right shoulder M Rheumatoid myopathy with rheumatoid arthritis of left shoulder M Rheumatoid myopathy with rheumatoid arthritis of right elbow M Rheumatoid myopathy with rheumatoid arthritis of left elbow M Rheumatoid myopathy with rheumatoid arthritis of right wrist M Rheumatoid myopathy with rheumatoid arthritis of left wrist M Rheumatoid myopathy with rheumatoid arthritis of right hand M Rheumatoid myopathy with rheumatoid arthritis of left hand M Rheumatoid myopathy with rheumatoid arthritis of right hip M Rheumatoid myopathy with rheumatoid arthritis of left hip M Rheumatoid myopathy with rheumatoid arthritis of right knee M Rheumatoid myopathy with rheumatoid arthritis of left knee M Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot M Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot M05.49 Rheumatoid myopathy with rheumatoid arthritis of multiple sites M33.02 Juvenile dermatopolymyositis with myopathy M33.12 Other dermatopolymyositis with myopathy M33.22 Polymyositis with myopathy M34.82 Systemic sclerosis with myopathy M35.03 Sicca syndrome with myopathy M48.50XA Collapsed vertebra, not elsewhere classified, site unspecified, initial encounter for fracture M48.51XA Collapsed vertebra, not elsewhere classified, occipitoatlantoaxial region, initial encounter for fracture M48.52XA Collapsed vertebra, not elsewhere classified, cervical region, initial encounter for fracture M48.53XA Collapsed vertebra, not elsewhere classified, cervicothoracic region, initial encounter for fracture M48.54XA Collapsed vertebra, not elsewhere classified, thoracic region, initial encounter for fracture

45 M48.55XA Collapsed vertebra, not elsewhere classified, thoracolumbar region, initial encounter for fracture M48.56XA Collapsed vertebra, not elsewhere classified, lumbar region, initial encounter for fracture M48.57XA Collapsed vertebra, not elsewhere classified, lumbosacral region, initial encounter for fracture M48.58XA Collapsed vertebra, not elsewhere classified, sacral and sacrococcygeal region, initial encounter for fracture M Muscle wasting and atrophy, not elsewhere classified, right shoulder M Muscle wasting and atrophy, not elsewhere classified, left shoulder M Muscle wasting and atrophy, not elsewhere classified, right upper arm M Muscle wasting and atrophy, not elsewhere classified, left upper arm M Muscle wasting and atrophy, not elsewhere classified, right forearm M Muscle wasting and atrophy, not elsewhere classified, left forearm M Muscle wasting and atrophy, not elsewhere classified, right hand M Muscle wasting and atrophy, not elsewhere classified, left hand M Muscle wasting and atrophy, not elsewhere classified, right thigh M Muscle wasting and atrophy, not elsewhere classified, left thigh M Muscle wasting and atrophy, not elsewhere classified, right lower leg M Muscle wasting and atrophy, not elsewhere classified, left lower leg M Muscle wasting and atrophy, not elsewhere classified, right ankle and foot M Muscle wasting and atrophy, not elsewhere classified, left ankle and foot M62.58 Muscle wasting and atrophy, not elsewhere classified, other site M62.59 Muscle wasting and atrophy, not elsewhere classified, multiple sites M62.81 Muscle weakness (generalized) M80.08XA Agerelated osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture M80.88XA Other osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture M84.58XA Pathological fracture in neoplastic disease, vertebrae, initial encounter for fracture M84.68XA Pathological fracture in other disease, other site, initial encounter for fracture M84.80 Other disorders of continuity of bone, unspecified site M Other disorders of continuity of bone, right shoulder M Other disorders of continuity of bone, left shoulder M Other disorders of continuity of bone, right humerus M Other disorders of continuity of bone, left humerus M M Other disorders of continuity of bone, right ulna Other disorders of continuity of bone, left radius M Other disorders of continuity of bone, right hand M Other disorders of continuity of bone, left hand M Other disorders of continuity of bone, right pelvic region and thigh M Other disorders of continuity of bone, left pelvic region and thigh

46 M M Other disorders of continuity of bone, right tibia Other disorders of continuity of bone, left fibula M Other disorders of continuity of bone, right ankle and foot M Other disorders of continuity of bone, left ankle and foot M84.88 Other disorders of continuity of bone, other site M84.9 Disorder of continuity of bone, unspecified M85.10 Skeletal fluorosis, unspecified site M Skeletal fluorosis, right shoulder M Skeletal fluorosis, left shoulder M Skeletal fluorosis, right upper arm M Skeletal fluorosis, left upper arm M Skeletal fluorosis, right forearm M Skeletal fluorosis, left forearm M Skeletal fluorosis, right hand M Skeletal fluorosis, left hand M Skeletal fluorosis, right thigh M Skeletal fluorosis, left thigh M Skeletal fluorosis, right lower leg M Skeletal fluorosis, left lower leg M Skeletal fluorosis, right ankle and foot M Skeletal fluorosis, left ankle and foot M85.18 Skeletal fluorosis, other site M85.19 Skeletal fluorosis, multiple sites M Other specified disorders of bone density and structure, right shoulder M Other specified disorders of bone density and structure, left shoulder M Other specified disorders of bone density and structure, right upper arm M Other specified disorders of bone density and structure, left upper arm M Other specified disorders of bone density and structure, right forearm M Other specified disorders of bone density and structure, left forearm M Other specified disorders of bone density and structure, right hand M Other specified disorders of bone density and structure, left hand M Other specified disorders of bone density and structure, right thigh M Other specified disorders of bone density and structure, left thigh M Other specified disorders of bone density and structure, right lower leg M Other specified disorders of bone density and structure, left lower leg M Other specified disorders of bone density and structure, right ankle and foot M Other specified disorders of bone density and structure, left ankle and foot M85.88 Other specified disorders of bone density and structure, other site M85.89 Other specified disorders of bone density and structure, multiple sites M Other disorders of bone development and growth, right shoulder M Other disorders of bone development and growth, left shoulder M Other disorders of bone development and growth, right humerus

47 M Other disorders of bone development and growth, left humerus M M Other disorders of bone development and growth, right ulna Other disorders of bone development and growth, left radius M Other disorders of bone development and growth, right hand M Other disorders of bone development and growth, left hand M Other disorders of bone development and growth, right femur M Other disorders of bone development and growth, left femur M M Other disorders of bone development and growth, right tibia Other disorders of bone development and growth, left fibula M Other disorders of bone development and growth, right ankle and foot M Other disorders of bone development and growth, left ankle and foot M89.28 Other disorders of bone development and growth, other site M89.29 Other disorders of bone development and growth, multiple sites M Hypertrophy of bone, right shoulder M Hypertrophy of bone, left shoulder M Hypertrophy of bone, right humerus M Hypertrophy of bone, left humerus M M Hypertrophy of bone, right ulna Hypertrophy of bone, left radius M Hypertrophy of bone, right hand M Hypertrophy of bone, left hand M Hypertrophy of bone, right femur M Hypertrophy of bone, left femur M M Hypertrophy of bone, right tibia Hypertrophy of bone, left fibula M Hypertrophy of bone, right ankle and foot M Hypertrophy of bone, left ankle and foot M89.38 Hypertrophy of bone, other site M89.39 Hypertrophy of bone, multiple sites M89.50 Osteolysis, unspecified site M Osteolysis, right shoulder M Osteolysis, left shoulder M Osteolysis, right upper arm M Osteolysis, left upper arm M Osteolysis, right forearm M Osteolysis, left forearm M Osteolysis, right hand M Osteolysis, left hand M Osteolysis, right thigh M Osteolysis, left thigh M Osteolysis, right lower leg M Osteolysis, left lower leg

48 M Osteolysis, right ankle and foot M Osteolysis, left ankle and foot M89.58 Osteolysis, other site M89.59 Osteolysis, multiple sites M89.8X0 Other specified disorders of bone, multiple sites M89.8X1 Other specified disorders of bone, shoulder M89.8X2 Other specified disorders of bone, upper arm M89.8X3 Other specified disorders of bone, forearm M89.8X4 Other specified disorders of bone, hand M89.8X5 Other specified disorders of bone, thigh M89.8X6 Other specified disorders of bone, lower leg M89.8X7 Other specified disorders of bone, ankle and foot M89.8X8 Other specified disorders of bone, other site M89.8X9 Other specified disorders of bone, unspecified site M94.1 Relapsing polychondritis M Chondrolysis, right hip M Chondrolysis, left hip M94.8X0 Other specified disorders of cartilage, multiple sites M94.8X1 Other specified disorders of cartilage, shoulder M94.8X2 Other specified disorders of cartilage, upper arm M94.8X3 Other specified disorders of cartilage, forearm M94.8X4 Other specified disorders of cartilage, hand M94.8X5 Other specified disorders of cartilage, thigh M94.8X6 Other specified disorders of cartilage, lower leg M94.8X7 Other specified disorders of cartilage, ankle and foot M94.8X8 Other specified disorders of cartilage, other site M94.8X9 Other specified disorders of cartilage, unspecified sites N32.89 Other specified disorders of bladder N32.9 Bladder disorder, unspecified N33 Bladder disorders in diseases classified elsewhere N40.0 N40.3 Enlarged prostate without lower urinary tract symptoms Nodular prostate with lower urinary tract symptoms N41.0 N41.4 Acute prostatitis Granulomatous prostatitis N41.8 Other inflammatory diseases of prostate N41.9 Inflammatory disease of prostate, unspecified N42.0 Calculus of prostate N42.1 Congestion and hemorrhage of prostate N42.3 Dysplasia of prostate N42.81 N42.83 Prostatodynia syndrome Cyst of prostate N42.89 Other specified disorders of prostate

49 N42.9 Disorder of prostate, unspecified N60.01 Solitary cyst of right breast N60.02 Solitary cyst of left breast N60.11 Diffuse cystic mastopathy of right breast N60.12 Diffuse cystic mastopathy of left breast N60.21 Fibroadenosis of right breast N60.22 Fibroadenosis of left breast N60.31 Fibrosclerosis of right breast N60.32 Fibrosclerosis of left breast N60.41 Mammary duct ectasia of right breast N60.42 Mammary duct ectasia of left breast N60.81 Other benign mammary dysplasias of right breast N60.82 Other benign mammary dysplasias of left breast N60.91 Unspecified benign mammary dysplasia of right breast N60.92 Unspecified benign mammary dysplasia of left breast N61 Inflammatory disorders of breast N62 Hypertrophy of breast N63 Unspecified lump in breast N64.0 N64.4 Fissure and fistula of nipple Mastodynia N64.51 N64.53 Induration of breast Retraction of nipple N64.59 Other signs and symptoms in breast N64.81 Ptosis of breast N64.82 Hypoplasia of breast N64.89 Other specified disorders of breast N64.9 Disorder of breast, unspecified N99.4 Postprocedural pelvic peritoneal adhesions N N Cystostomy hemorrhage Cystostomy malfunction N Other cystostomy complication Q85.00 Q85.02 Neurofibromatosis, unspecified Neurofibromatosis, type 2 R11.10 Vomiting, unspecified R11.13 Vomiting of fecal matter R18.0 Malignant ascites R18.8 Other ascites R22.0 R22.2 Localized swelling, mass and lump, head Localized swelling, mass and lump, trunk R59.0 Localized enlarged lymph nodes R59.1 Generalized enlarged lymph nodes R59.9 Enlarged lymph nodes, unspecified

50 R Other abnormal cytological findings on specimens from cervix uteri R Unspecified abnormal cytological findings in specimens from cervix uteri R Unspecified abnormal cytological findings in specimens from vagina R89.7 Abnormal histological findings in specimens from other organs, systems and tissues R90.0 Intracranial spaceoccupying lesion found on diagnostic imaging of central nervous system R97.2 Elevated prostate specific antigen [PSA] T86.01 T86.03 Bone marrow transplant rejection Bone marrow transplant infection T86.09 Other complications of bone marrow transplant T86.11 T86.13 Kidney transplant rejection Kidney transplant infection T86.19 Other complication of kidney transplant T86.21 T86.23 Heart transplant rejection Heart transplant infection T Cardiac allograft vasculopathy T Other complications of heart transplant T86.31 T86.33 Heartlung transplant rejection Heartlung transplant infection T86.39 Other complications of heartlung transplant T86.41 T86.43 Liver transplant rejection Liver transplant infection T86.49 Other complications of liver transplant T T Lung transplant rejection Lung transplant infection T Other complications of lung transplant T T Bone graft rejection Bone graft infection T Other complications of bone graft T T Intestine transplant rejection Intestine transplant infection T Other complications of intestine transplant T T Other transplanted tissue rejection Other transplanted tissue infection T Other complications of other transplanted tissue T86.90 T86.93 Unspecified complication of unspecified transplanted organ and tissue Unspecified transplanted organ and tissue infection T86.99 Other complications of unspecified transplanted organ and tissue Z03.6* Encounter for observation for suspected toxic effect from ingested substance ruled out Z03.89* Encounter for observation for other suspected diseases and conditions ruled out Z Personal history of malignant carcinoid tumor of stomach

51 Z Personal history of malignant carcinoid tumor of large intestine Z Personal history of malignant carcinoid tumor of rectum Z Personal history of malignant carcinoid tumor of small intestine Z Personal history of malignant carcinoid tumor of bronchus and lung Z Personal history of malignant carcinoid tumor of thymus Z Personal history of malignant carcinoid tumor of kidney Z ICD10 Codes that DO NOT Support Medical Necessity Additional ICD10 Information N/A General Information Associated Information The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Not applicable It is generally not medically necessary to perform more than 10 analyses on a single sample. Services exceeding this parameter may be subject to review. Sources of Information and Basis for Decision This bibliography presents those sources that were obtained during the development of this policy. CGS Adminstrators, LLC is not responsible for the continuing viability of Web site addresses listed below. Abeloff: Clinical Oncology. 3rd ed. Churchill Livingstone; Coons AH, Creech HJ, Jones RN. Immunologic properties of an antibody containing a fluorescent group. Proceedings of the Society of Experimental Biological Medicine. 1941:47;

52 Hoffman: Hematology: Basic Principles and Practice. 4th ed. Churchill Livingstone Jhala N, Lechago BS, Lechago S, Younes J. Is immunostaining for helicobacter pylori superior to the special stain Thiazine in detecting small numbers of h. pylori in gastric biopsies? Applied Immunohistochemistry and Molecular Morphology. 2002;10(1):8284. Jhala N, Siegal G, Lemm K, Klemm K, et al. Infiltration of helicopbacter pylori in the gastric mucosa. American Society for Clinical Pathology. 2003;119: Marzio L, Angelucci D, Grossi L, et al. AntiHelicobacter pylori, specific antibody immunohistochemistry improves the diagnostic accuracy of helicobacter pylori in the biopsy specimen from patients treated with triple therapy. The American Journal of Gastroenterology. 1998;93:2. McPherson & Pincus: Henry's Clinical Diagnosis and Management by Laboratory Methods. 21st ed. W B Saunders Co The following references were used in adjudicating policy revisions and /or reconsideration requests: Alaibac M, Tonin E, Peserico A and VellerFornasa C. Cutaneous lymphomas. ACTA. 2001;10:2. Burg G, Kempf W, Cozzio A, et al. WHO/EORTC classification of cutaneous lymphomas 2005: histological and molecular aspects. J Cutan Pathol. 2005;32: Kovich O, Soldano A. Clinical pathologic correlations for diagnosis and treatment of nail disorders. Dermatologic Therapy. 2007:20:1116. Megahed M. Histopathology of Blistering Diseases, With Clinical, Electron Microscopic, Immunological and Molecular Biological Correlations. Springer. 2004; Sources Reviewed with Reconsideration Request Submitted May 2010 Chan JKC. Advances in immunohistochemistry: impact on surgical pathology practice. Seminars in Diagnostic Pathology. 2000;27(3): Eshun JK, Black DD, Casteel HB, et al. Comparison of immunohistochemistry and silver stain for the diagnosis of pediatric heliobacter pylori infection in ureasenegative gastric biopsies. Pediatric and Developmental Pathology.2001;4:8288. Ezyaguirre EJ, Walker DH, Zaki S. Chapter 3Immunohistology of infectious diseases. In: Dabbs JD. Diagnostic Immunohistochemistry: Theranostic and Genomic Applications, 3rd Edition. Jaffer S, Bleiweiss IJ. Beyond hematoxylin and eosinthe role of immunohistochemistry in surgical pathology. Cancer Investigation. 2004;22(3):

53 Jonkers D, Stobberingh E, de Bruine A, Arends JW, Stockbrugger R. Evaluation of immunohistochemistry for the detection of heliobater pylori in gastric mucosal biopsies. Journal of Infection. 1997;35: Luttrell WE. Uranyl nitrate. Journal of Chemical Health & Safety. 2009:4042. Revision History Information Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of "R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct row. Revision History Date 10/01/2014 R1 Revision History Number Revision History Explanation Revision #: R1 Revision Effective:10/01/2014 Revision Explanation: was replace by g0461 and G /01/14. Reason(s) for Change Revisions Due To CPT/HCPCS Code Changes Associated Documents Attachments N/A Related Local Coverage Documents Article(s) A52386 Immunohistochemistry Supplemental Instructions Article Related National Coverage Documents N/A Public Version(s) Updated on 05/13/2014 with effective dates 10/01/2014 N/A Updated on 03/17/2014 with effective dates 10/01/2014 N/A Local Coverage Article: Immunohistochemistry Supplemental Instructions Article (A52386)

54 Contractor Information Contractor Name CGS Administrators, LLC Contractor Information Table Article Information General Information General Article Information Table Article ID A52386 Original ICD9 Article ID A50751 Article Title Immunohistochemistry Supplemental Instructions Article AMA CPT / ADA CDT Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT2010 are trademarks of the American Dental Association. Original Effective Date 10/01/2014 Revision Effective Date 10/01/2014 Revision Ending Date N/A Retirement Date N/A

55 Article Guidance Article Text: The information in this Supplemental Instructions Article (SIA) contains coding or other guidelines that complement the Local Coverage Determination (LCD) for Immunohistochemistry. The LCD can be accessed through our contractor Web site at It can also be found on the Medicare Coverage Database at Coding Guidelines: General Guidelines for claims submitted to Part A or Part B MAC: Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD10CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines An ABN may be used for services which are likely to be noncovered, whether for medical necessity or for other reasons. Refer to CMS Publication 10004, Medicare Claims Processing Manual, Chapter 30, for complete instructions. Effective from April 1, 2010, noncovered services should be billed with modifier GA, GX, GY, or GZ, as appropriate. The GA modifier ( Waiver of Liability Statement Issued as Required by Payer Policy ) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMSR131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.

56 Modifier GX ( Notice of Liability Issued, Voluntary Under Payer Policy ) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if noncovered services are reported with modifier GX, FI and Part A MAC systems will automatically deny the services. The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily noncovered, or without a benefit category, submit the appropriate CPT/HCPCS code with the GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny. Specific coding guidelines for this policy: CPT Code may be used for each antibody selected. The service may be billed in its entirety, i.e., accession, examination and interpretation; or as the technical and professional components, i.e., 88342TC and respectively. CPT Code may be billed with other pathology services rendered on the same day. The following consultation codes should not be used with this service: 88321, 88325, , For claims submitted to the Part B MAC: All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim. Claims for Immunohistochemistry services are payable under Medicare Part B in the following places of service: For the global: CPT code is payable in the following places of service for Part B MACs: office (11), independent clinic (49), state or local public health clinic (71) and independent laboratory (81). For the technical component (modifier TC): CPT code are payable in the following places of service for Part B MACs: office (11), independent clinic (49), federally qualified health center (50), state or local public health clinic (71), rural health clinic (72) and independent laboratory (81). For the professional component (modifier 26): CPT code is payable in the following

57 places of service for Part B MACs: office (11), inpatient hospital (21), outpatient hospital (22), ambulatory surgery center (24), independent clinic (49), state or local public health clinic (71), and independent laboratory (81). CPT code is not a billable expense by the ASC. For claims submitted to the Part A MAC: Hospital Inpatient Claims: The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission. The hospital enters ICD10CM codes for up to eight additional conditions in FLs 67A 67Q if they coexisted at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67. For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication 10004, Medicare Program Integrity Manual, Chapter 25, Section 75 for additional instructions.) Hospital Outpatient Claims: The hospital should report the full ICD10CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD10CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (Z00.00Z13.9). The hospital enters the full ICD10CM codes in FLs 67A67Q for up to eight other diagnoses that coexisted in addition to the diagnosis reported in FL 67. For dates of service prior to April 1, 2010, FQHC services should be reported with bill type 73X. For dates of service on or after April 1, 2010, bill type 77X should be used to report FQHC services. Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to

58 that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims. Bill Type Codes Information Table 011x Hospital Inpatient (Including Medicare Part A) 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 014x Hospital Laboratory Services Provided to Nonpatients 021x Skilled Nursing Inpatient (Including Medicare Part A) 022x Skilled Nursing Inpatient (Medicare Part B only) 023x Skilled Nursing Outpatient 071x Clinic Rural Health 073x Clinic Freestanding 077x Clinic Federally Qualified Health Center (FQHC) 085x Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the article services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. Revenue codes only apply to providers who bill these services to the Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the Part B MAC. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes. All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review. The Revenue Codes Information Table 0310 Laboratory Pathology General Classification 0311 Laboratory Pathology Cytology

59 0312 Laboratory Pathology Histology 0314 Laboratory Pathology Biopsy 0319 Laboratory Pathology Other Laboratory Pathology 0521 FreeStanding Clinic Clinic Visit by Member to RHC/FQHC 096X Professional Fees General Classification 0971 Professional Fees Laboratory CPT/HCPCS Codes Group 1 Paragraph: Effective 01/01/ is no longer a valid code and replaced with G0461 and G0462. Group 1 Codes: CPT/HCPCS Codes Information Table G0461 G0462 IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, PER SPECIMEN; FIRST SINGLE OR MULTIPLEX ANTIBODY STAIN IMMUNOHISTOCHEMISTRY OR IMMUNOCYTOCHEMISTRY, PER SPECIMEN; EACH ADDITIONAL SINGLE OR MULTIPLEX ANTIBODY STAIN (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) ICD10 Codes that are Covered ICD10 Codes that are Not Covered N/A Revision History Information Please note: The Revision History information included in this Article prior to 06/20/2013 will now display with a Revision History Number of "R1" at the bottom of this table. All new Revision History information entries completed on or after 06/20/2013 will display as a row in the Revision History section of the Article and numbering will begin with "R2". Revision History Date 10/01/2014 R1 Revision History Number Revision History Explanation Revision Effective date: 10/01/2014 Revision Explanation: CPT is no longer a valid code for

60 Medicare and is replaced with G0461 and G0462 effective 01/01/2014. Associated Documents Related Local Coverage Document(s) N/A Related National Coverage Document(s) N/A Statutory Requirements URL(s) N/A Rules and Regulations URL(s) N/A CMS Manual Explanations URL(s) N/A Other URL(s) N/A Public Version(s) Updated on 05/29/2014 with effective dates 10/01/2014 N/A