Services That Are Not Reasonable and Necessary 08/25/15

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1 Medicare National and Local Coverage Determination Policy PA, NJ, MD, DC, DE Policies in this MLCP Reference Guide apply to testing performed at a Quest Diagnostics facility and apply to Medicare National Coverage Determination Policy. This diagnosis code reference guide is provided as an aid to physicians and office staff in determining when an ABN (Advance Beneficiary Notice) is necessary. Diagnosis codes must be applicable to the patient s symptoms or conditions and must be consistent with documentation in the patient s medical record. Quest Diagnostics does not recommend any diagnosis codes and will only submit diagnosis information provided to us by the ordering physician or his/her designated staff. The CPT codes provided are based on AMA guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed. Click here for National MLCP Policies Tool Document contains information on National Medicare Limited Coverage Policies Alpha-Fetoprotein Blood Counts Blood Glucose Testing Carcinoembryonic Antigen Collagen Crosslinks - Any Method Digoxin Therapeutic Drug Assay Fecal Occult Blood Gamma Glutamyl Transferase Glycated Hemoglobin - Glycated Protein Hepatitis Panel/Acute Hepatitis Panel Human Chorionic Gonadotropin Human Immunodeficiency Virus (HIV) Testing (Diagnosis) Human Immunodeficiency Virus (HIV) Testing (Prognosis Including Monitoring) Lipids Testing Partial Thromboplastin Time (PTT) Prostate Specific Antigen Prothrombin Time (PT) Serum Iron Studies Thyroid Testing Tumor Antigen by Immunoassay CA 15-3 CA Tumor Antigen by Immunoassay CA 19-9 Tumor Antigen by Immunoassay CA-125 Urine Culture, Bacterial Click policy below for Local MLCP Policy Tool Document contains the below Medicare Local Limited Coverage Policies for lab testing performed in DE, DC, MD, NJ, PA. Allergy Testing Biomarker for Oncology Biomarker Overview C-Reactive Protein High Sensitivity Testing Flow Cytometry Moh s Micrographic Surgery Molecular Diagnostics: Genitourinary Infectious Disease Testing Qualitative Drug Screening Vitamin D Assay Testing Services That Are Not Reasonable and Necessary QuestDiagnostics.com 08/25/15

2 Medicare Local Coverage Determination Policy PA, NJ, MD, DC, DE L35771 Allergy Testing Allergen Specific IgE (Page 1 of 3) CPT Code: Data Source: LCD Description: In order for allergy testing to be considered reasonable and necessary by Medicare, antigens must meet all the following criteria - skin testing must be performed based on history and physical exam, proven efficacy as demonstrated through scientifically valid medical studies published in peer-review journal, and exist in the patient's environment with a reasonable probability of exposure. ICD-9-CM Codes that Support Medical Necessity The Allergy test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. FOR CPT ONLY ASPERGILLOSIS ACUTE CONJUNCTIVITIS UNSPECIFIED ACUTE ATOPIC CONJUNCTIVITIS VERNAL CONJUNCTIVITIS OTHER CHRONIC ALLERGIC CONJUNCTIVITIS ACUTE SEROUS OTITIS MEDIA OTHER AND UNSPECIFIED CHRONIC NONSUPPURATIVE OTITIS MEDIA UNSPECIFIED OTITIS MEDIA ACUTE MAXILLARY SINUSITIS - ACUTE SINUSITIS UNSPECIFIED 462 ACUTE PHARYNGITIS 463 ACUTE TONSILLITIS ACUTE LARYNGITIS WITHOUT OBSTRUCTION ACUTE LARYNGITIS WITH OBSTRUCTION SUPRAGLOTTITIS UNSPECIFIED WITHOUT OBSTRUCTION SUPRAGLOTTITIS UNSPECIFIED WITH OBSTRUCTION ACUTE BRONCHITIS POLYP OF NASAL CAVITY OTHER POLYP OF SINUS UNSPECIFIED NASAL POLYP CHRONIC MAXILLARY SINUSITIS - CHRONIC ETHMOIDAL SINUSITIS ALLERGIC RHINITIS DUE TO POLLEN ALLERGIC RHINITIS DUE TO OTHER ALLERGEN ALLERGIC RHINITIS CAUSE UNSPECIFIED HYPERTROPHY OF NASAL TURBINATES OTHER DISEASE OF NASAL CAVITY AND SINUSES EXTRINSIC ASTHMA UNSPECIFIED - ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION OTHER SPECIFIED GASTRITIS (WITHOUT HEMORRHAGE) OTHER ATOPIC DERMATITIS AND RELATED CONDITIONS DERMATITIS DUE TO FOOD TAKEN INTERNALLY UNSPECIFIED PRURITIC DISORDER ALLERGIC URTICARIA IDIOPATHIC URTICARIA DERMATOGRAPHIC URTICARIA OTHER SPECIFIED URTICARIA UNSPECIFIED URTICARIA RESPIRATORY ABNORMALITY OTHER COUGH TOXIC EFFECT OF VENOM TOXIC EFFECT OF LATEX OTHER ANAPHYLACTIC REACTION ANGIONEUROTIC EDEMA NOT ELSEWHERE CLASSIFIED UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE OTHER DRUG ALLERGY THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED. 08/13/15

3 Medicare Local Coverage Determination Policy PA, NJ, MD, DC, DE L35771 Allergy Testing - Allergen Specific IgE (Page 2 of 3) CPT Code: LCD Description: In order for allergy testing to be considered reasonable and necessary by Medicare, antigens must meet all the following criteria - skin testing must be performed based on history and physical exam, proven efficacy as demonstrated through scientifically valid medical studies published in peer-review journal, and exist in the patient's environment with a reasonable probability of exposure. ICD-9-CM Codes that Support Medical Necessity The Allergy test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. FOR CPT ONLY UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE ALLERGY UNSPECIFIED NOT ELSEWHERE CLASSIFIED MEDICINAL AND BIOLOGICAL SUBSTANCE ANAPHYLACTIC REACTION DUE TO ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS - ANAPHYLACTIC REACTION DUE TO OTHER SERUM OTHER SERUM REACTION DUE TO ADMINISTRATION OF BLOOD AND BLOOD PRODUCTS - OTHER SERUM REACTION ANAPHYLACTIC REACTION DUE TO UNSPECIFIED FOOD - ANAPHYLACTIC REACTION DUE TO OTHER SPECIFIED FOOD V12.00* PERSONAL HISTORY OF UNSPECIFIED INFECTIOUS AND PARASITIC DISEASE V V14.9 PERSONAL HISTORY OF ALLERGY TO PENICILLIN - PERSONAL HISTORY OF ALLERGY TO UNSPECIFIED MEDICINAL AGENT V V15.09 PERSONAL HISTORY OF ALLERGY TO PEANUTS - PERSONAL HISTORY OF OTHER ALLERGY OTHER THAN TO MEDICINAL AGENTS V67.59 OTHER FOLLOW-UP EXAMINATION *Note: V12.00 Personal History of infectious and parasitic disease should be used for recurrent pyogenic infections. THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED. 08/13/15

4 Medicare Local Coverage Determination Policy PA, NJ, MD, DC, DE L35771 Allergy Testing Assay of IgE (Page 3 of 3) CPT Code: LCD Description: In order for allergy testing to be considered reasonable and necessary by Medicare, antigens must meet all the following criteria - skin testing must be performed based on history and physical exam, proven efficacy as demonstrated through scientifically valid medical studies published in peer-review journal, and exist in the patient's environment with a reasonable probability of exposure. ICD-9-CM Codes that Support Medical Necessity The Allergy test is determined to be medically necessary by Medicare only when it is ordered for patients with one of the conditions listed below. ICD-9-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. FOR CPT Aspergillosis Other Atopic Dermatitis And Related Conditions Allergic Urticaria Dermatographic Urticaria Toxic Effect Of Venom Toxic Effect Of Latex OTHER ANAPHYLACTIC Reaction Anaphylactic Reaction Due To Unspecified Food Anaphylactic Reaction Due To Peanuts Anaphylactic Reaction Due To Crustaceans Anaphylactic Reaction Due To Fruits And Vegetables Anaphylactic Reaction Due To Tree Nuts And Seeds Anaphylactic Reaction Due To Fish Anaphylactic Reaction Due To Food Additives Anaphylactic Reaction Due To Milk Products Anaphylactic Reaction Due To Eggs Anaphylactic Reaction Due To Other Specified Food V12.00* Personal History Of Unspecified Infectious And Parasitic Disease V67.59 Other Follow-up Examination *Note: V12.00 Personal History of infectious and parasitic disease should be used for recurrent pyogenic infections. THE CPT CODES PROVIDED ARE BASED ON AMA GUIDELINES AND ARE FOR INFORMATIONAL PURPOSES ONLY. CPT CODING IS THE SOLE RESPONSIBILITY OF THE BILLING PARTY. PLEASE DIRECT ANY QUESTIONS REGARDING CODING TO THE PAYER BEING BILLED. 08/13/15

5 Medicare Local Coverage Determination Policy - PA, NJ, MD, DC, DE C-Reactive Protein Testing Data Source CPT Code: LCD Description: C-Reactive Protein, (CRP), is a nonspecific, acute-phase reactant produced in response to tissue injury, inflammation or infection. As an acute phase reactant, concentrations rise rapidly and half-life is short. Recent studies have shown that chronic, low-grade inflammation contributes to atherogenesis and the development of coronary artery disease (CAD). Inflammatory changes lead to progressive disease, which culminates in plaque instability, rupture, thrombosis, and myocardial infarction (MI). ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference PURE HYPERCHOLESTEROLEMIA PURE HYPERGLYCERIDEMIA MIXED HYPERLIPIDEMIA HYPERCHYLOMICRONEMIA OTHER AND UNSPECIFIED HYPERLIPIDEMIA CORONARY ATHEROSCLEROSIS OF NATIVE CORONARY ARTERY V49.89* OTHER SPECIFIED CONDITIONS INFLUENCING HEALTH STATUS Note: per Novitas Medicare LCD policy *Use ICD-9-CM code V49.89 for patients at intermediate risk for CAD who do not have elevated lipids (i.e., do not meet criteria to use ICD-9-CM codes ) Utilization Guidelines Generally, the measurement of hscrp markers is performed twice (averaging results), optimally two weeks apart and fasting or nonfasting, with the average expressed in mg/l, in metabolically stable patients. If an average CRP level of >10.0 mg/l is found on two tests performed 2 weeks apart, a third test may be performed after ruling out possible infectious or inflammatory causes for the increase (AHA/CDC Recommendation). 09/01/14

6 Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Flow Cytometry (1 of 4) CPT Code: 88184, 88185, 88187, 88188, LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical analysis and interpretations are done by an experienced physician, usually a pathologist. ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference. 042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE I [HTLV-I] - HUMAN IMMUNODEFICIENCY VIRUS TYPE 2 [HIV-2] SECONDARY MALIGNANT NEOPLASM OF PLEURA SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM RETICULOSARCOMA UNSPECIFIED SITE - RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES LYMPHOSARCOMA UNSPECIFIED SITE - LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE - BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MARGINAL ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S GRANULOMA UNSPECIFIED SITE - HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S SARCOMA UNSPECIFIED SITE - HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE - HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE - HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE - HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE - HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES MYCOSIS FUNGOIDES UNSPECIFIED SITE - MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES 09/01/14

7 Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Flow Cytometry (2 of 4) CPT Code: 88184, 88185, 88187, 88188, LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical analysis and interpretations are done by an experienced physician, usually a pathologist. ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference SEZARY'S DISEASE UNSPECIFIED SITE - SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE - MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE - LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES LETTERER-SIWE DISEASE UNSPECIFIED SITE - LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE - MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE - OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MULTIPLE MYELOMA, IN RELAPSE PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - PLASMA CELL LEUKEMIA, IN RELAPSE OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE LYMPHOID LEUKEMIA, IN RELAPSE CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER LYMPHOID LEUKEMIA, IN RELAPSE UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MYELOID LEUKEMIA, IN RELAPSE CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC MYELOID LEUKEMIA, IN RELAPSE SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE MYELOID LEUKEMIA, IN RELAPSE MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MYELOID SARCOMA, IN RELAPSE OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER MYELOID LEUKEMIA, IN RELAPSE 09/01/2014

8 Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Flow Cytometry (3 of 4) CPT Code: 88184, 88185, 88187, 88188, LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical analysis and interpretations are done by an experienced physician, usually a pathologist. ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER MONOCYTIC LEUKEMIA, IN RELAPSE UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC ERYTHREMIA, IN RELAPSE MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MEGAKARYOCYTIC LEUKEMIA, IN RELAPSE OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER SPECIFIED LEUKEMIA, IN RELAPSE ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION CHRONICLEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED LEUKEMIA, IN RELAPSE ESSENTIAL THROMBOCYTHEMIA - POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD) OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES MONOCLONAL PARAPROTEINEMIA - MACROGLOBULINEMIA OTHER DISORDERS OF PLASMA PROTEIN METABOLISM - UNSPECIFIED DISORDER OF PLASMA PROTEIN METABOLISM HYPOGAMMAGLOBULINEMIA UNSPECIFIED - COMMON VARIABLE IMMUNODEFICIENCY OTHER DEFICIENCY OF HUMORAL IMMUNITY IMMUNODEFICIENCY WITH PREDOMINANT T-CELL DEFECT UNSPECIFIED - NEZELOF'S SYNDROME OTHER DEFICIENCY OF CELL-MEDIATED IMMUNITY COMBINED IMMUNITY DEFICIENCY - UNSPECIFIED IMMUNITY DEFICIENCY AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME AUTOIMMUNE DISEASE, NOT ELSEWHERE CLASSIFIE 09/01/2014

9 Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Flow Cytometry (4 of 4) CPT Code: 88184, 88185, 88187, 88188, LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical analysis and interpretations are done by an experienced physician, usually a pathologist. ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference OTHER SPECIFIED DISORDERS INVOLVING THE IMMUNE MECHANISM - UNSPECIFIED DISORDER OF IMMUNE MECHANISM OTHER HEMOGLOBINOPATHIES HEMOGLOBINURIA DUE TO HEMOLYSIS FROM EXTERNAL CAUSES CONSTITUTIONAL RED BLOOD CELL APLASIA OTHER CONSTITUTIONAL APLASTIC ANEMIA ANTINEOPLASTIC CHEMOTHERAPY INDUCED PANCYTOPENIA - OTHER DRUG INDUCED PANCYTOPENIA OTHER PANCYTOPENIA MYELOPHTHISIS RED CELL APLASIA (ACQUIRED) (ADULT) (WITH THYMOMA) OTHER SPECIFIED APLASTIC ANEMIAS APLASTIC ANEMIA UNSPECIFIED SIDEROBLASTIC ANEMIA ANEMIA IN NEOPLASTIC DISEASE OTHER SPECIFIED ANEMIAS - ANEMIA UNSPECIFIED PRIMARY THROMBOCYTOPENIA,UNSPECIFIED - CONGENITAL AND EREDITARY THROMBOCYTOPENIC PURPURA OTHER PRIMARY THROMBOCYTOPENIA THROMBOCYTOPENIA UNSPECIFIED NEUTROPENIA, UNSPECIFIED - NEUTROPENIA DUE TO INFECTION OTHER NEUTROPENIA FUNCTIONAL DISORDERS OF POLYMORPHONUCLEAR NEUTROPHILS - HEMOPHAGOCYTIC SYNDROMES LEUKOCYTOPENIA, UNSPECIFIED LYMPHOCYTOPENIA OTHER DECREASED WHITE BLOOD CELL COUNT LEUKOCYTOSIS, UNSPECIFIED BASOPHILIA OTHER ELEVATED WHITE BLOOD CELL COUNT OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS - UNSPECIFIED DISEASE OF WHITE BLOOD CELLS HYPERSPLENISM DISEASE OF SPLEEN UNSPECIFIED NEUTROPENIC OTHER DISEASES OF SPLEEN MYELOFIBROSIS UNSPECIFIED DISEASES OF BLOOD AND BLOOD-FORMING ORGANS 452 PORTAL VEIN THROMBOSIS EMBOLISM AND THROMBOSIS OF UNSPECIFIED SITE ENLARGEMENT OF LYMPH NODES SPLENOMEGALY PROTEINURIA OTHER NONSPECIFIC ABNORMAL HISTOLOGICAL FINDINGS COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN 09/01/2014 V08 ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION STATUS V V10.63 PERSONAL HISTORY OF UNSPECIFIED LEUKEMIA - PERSONAL HISTORY OF MONOCYTIC LEUKEMIA V10.69 PERSONAL HISTORY OF OTHER LEUKEMIA V10.91 PERSONAL HISTORY OF MALIGNANT NEUROENDOCRINE TUMOR V V42.7 KIDNEY REPLACED BY TRANSPLANT - LIVER REPLACED BY TRANSPLANT V V42.84 BONE MARROW REPLACED BY TRANSPLANT - ORGAN OR TISSUE REPLACED BY TRANSPLANT INTESTINES V42.89 OTHER SPECIFIED ORGAN OR TISSUE REPLACED BY TRANSPLANT V42.9 UNSPECIFIED ORGAN OR TISSUE REPLACED BY TRANSPLANT SPLENOMEGALY

10 Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Flow Cytometry: Cell Cycle or DNA Analysis CPT Code: LCD Description: Flow Cytometry is a highly complex process by which blood, body fluids, bone marrow and tissue can be examined. It provides important immunophenotypic and DNA cycle information, of both diagnostic and prognostic interest in hematopathology, cytopathology and general surgical pathology. The technique measures multiple characteristics (cell size, internal structure, antigens, DNA, ploidy and cell cycle analysis) of single cells in a moving fluid stream. Clinical analysis and interpretations are done by an experienced physician, usually a pathologist. ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS - MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH - MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION MALIGNANT NEOPLASM OF RECTUM MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST - MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST MALIGNANT NEOPLASM OF OVARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA 185 MALIGNANT NEOPLASM OF PROSTATE MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER - MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED 193 MALIGNANT NEOPLASM OF THYROID GLAND MALIGNANT NEOPLASM OF ADRENAL GLAND SECONDARY MALIGNANT NEOPLASM OF BREAST MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION MULTIPLE MYELOMA IN REMISSION BENIGN NEOPLASM OF ADRENAL GLAND CARCINOMA IN SITU OF BREAST CARCINOID SYNDROME 09/01/2014

11 Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Moh s Micrographic Surgery (1 of 2) CPT Code: 88304, 88305, 88307, 88331, 88332, LCD Description: Moh s Micrographic Surgery (MMS) is a microscopically controlled tissue-sparing surgical technique of removing complex or ill-defined cancerous tissues of the skin. The surgery is usually performed in an outpatient setting under local anesthesia, with or without sedation. MMS involves obtaining of tangential specimen of tumor with a minimal margin of clinically normal-appearing tissue, precisely mapped, and processed immediately by frozen section for microscopic examination. This process of removal of complex or ill-defined skin cancer requires a single physician to act in two integrated, but separate and distinct capacities: surgeon and pathologist, trained and highly skilled in MMS techniques and pathology identification. ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM Codes book should be used as a complete reference MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF LIP UNSPECIFIED VERMILION BORDER MALIGNANT NEOPLASM OF BASE OF TONGUE - MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH - MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED MALIGNANT NEOPLASM OF CHEEK MUCOSA - MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED MALIGNANT NEOPLASM OF NASAL CAVITIES MALIGNANT NEOPLASM OF MAXILLARY SINUS - MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED MALIGNANT NEOPLASM OF GLOTTIS MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK - MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED MALIGNANT MELANOMA OF SKIN OF LIP - MELANOMA OF SKIN SITE UNSPECIFIED UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP - OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED MALIGNANT NEOPLASM OF LABIA MAJORA - MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED MALIGNANT NEOPLASM OF PREPUCE - MALIGNANT NEOPLASM OF PENIS PART UNSPECIFIED MALIGNANT NEOPLASM OF SCROTUM - MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE UNSPECIFIED MALIGNANT POORLY DIFFERENTIATED NEUROENDOCRINE CARCINOMA, ANY SITE - MERKEL CELL CARCINOMA OF OTHER SITES CARCINOMA IN SITU OF SKIN OF LIP - CARCINOMA IN SITU OF SKIN SITE UNSPECIFIED CARCINOMA IN SITU, VAGINA CARCINOMA IN SITU, VULVA CARCINOMA IN SITU, OTHER FEMALE GENITAL ORGAN CARCINOMA IN SITU OF OTHER AND UNSPECIFIED MALE GENITAL ORGANS NEOPLASM OF UNCERTAIN BEHAVIOR OF CONNECTIVE AND OTHER SOFT TISSUE NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN HYPOGAMMAGLOBULINEMIA UNSPECIFIED - UNSPECIFIED DISORDER OF IMMUNE MECHANISM ATHEROSCLEROSIS OF AORTA ATHEROSCLEROSIS OF RENAL ARTERY ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION 01/01/15

12 Medicare Local Coverage Determination Policy (PA, NJ, DC, MD, DE) Moh s Micrographic Surgery (2 of 2) CPT Code: 88304, 88305, 88307, 88331, 88332, LCD Description: Moh s Micrographic Surgery (MMS) is a microscopically controlled tissue-sparing surgical technique of removing complex or ill-defined cancerous tissues of the skin. The surgery is usually performed in an outpatient setting under local anesthesia, with or without sedation. MMS involves obtaining of tangential specimen of tumor with a minimal margin of clinically normal-appearing tissue, precisely mapped, and processed immediately by frozen section for microscopic examination. This process of removal of complex or ill-defined skin cancer requires a single physician to act in two integrated, but separate and distinct capacities: surgeon and pathologist, trained and highly skilled in MMS techniques and pathology identification. ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE OTHER ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE EXTREMITIES ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTREMITIES ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES CHRONIC TOTAL OCCLUSION OF ARTERY OF THE EXTREMITIES ATHEROSCLEROSIS OF OTHER SPECIFIED ARTERIES GENERALIZED AND UNSPECIFIED ATHEROSCLEROSIS THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE) PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE ERYTHROMELALGIA OTHER PERIPHERAL VASCULAR DISEASE PERIPHERAL VASCULAR DISEASE UNSPECIFIED ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY EMBOLISM AND THROMBOSIS OF ILIAC ARTERY PHLEBITIS AND THROMBOPHLEBITIS OF SUPERFICIAL VESSELS OF LOWER EXTREMITIES PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (DEEP) (SUPERFICIAL) PHLEBITIS AND THROMBOPHLEBITIS OF OTHER PHLEBITIS AND THROMBOPHLEBITIS OF LOWER EXTREMITIES UNSPECIFIED VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER - ASYMPTOMATIC VARICOSE VEINS POSTMASTECTOMY LYMPHEDEMA SYNDROME OTHER LYMPHEDEMA POSTPHLEBETIC SYNDROME WITHOUT COMPLICATIONS - POSTPHLEBETIC SYNDROME WITH OTHER COMPLICATION COMPRESSION OF VEIN VENOUS (PERIPHERAL) INSUFFICIENCY UNSPECIFIED OTHER SPECIFIED CIRCULATORY SYSTEM DISORDERS DERMATITIS DUE TO OTHER RADIATION HEREDITARY EDEMA OF LEGS EDEMA CHEMICAL BURN OF EYELIDS AND PERIOCULAR AREA - BURN WITH RESULTING RUPTURE AND DESTRUCTION OF EYEBALL 01/01/15

13 Medicare Local Coverage Determination Policy - PA, NJ, MD, DC, DE Qualitative Drug Testing (Page 1 of 2) CPT Code: G0431, G0434 LCD Description: A qualitative drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. However, urine is the best specimen for broad qualitative screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants. ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference ACIDOSIS SIMPLE TYPE SCHIZOPHRENIA UNSPECIFIED STATE DISORGANIZED TYPE SCHIZOPHRENIA UNSPECIFIED STATE CATATONIC TYPE SCHIZOPHRENIA UNSPECIFIED STATE PARANOID TYPE SCHIZOPHRENIA UNSPECIFIED STATE OPIOID TYPE DEPENDENCE CONTINUOUS USE UNSPECIFIED DRUG DEPENDENCE UNSPECIFIED USE OTHER MIXED OR UNSPECIFIED DRUG ABUSE UNSPECIFIED USE GENERALIZED CONVULSIVE EPILEPSY WITHOUT INTRACTABLE EPILEPSY GENERALIZED CONVULSIVE EPILEPSY WITH INTRACTABLE EPILEPSY GRAND MAL STATUS EPILEPTIC EPILEPSY UNSPECIFIED WITHOUT INTRACTABLE EPILEPSY EPILEPSY UNSPECIFIED WITH INTRACTABLE EPILEPSY ATRIOVENTRICULAR BLOCK UNSPECIFIED FIRST DEGREE ATRIOVENTRICULAR BLOCK MOBITZ (TYPE) II ATRIOVENTRICULAR BLOCK OTHER SECOND DEGREE ATRIOVENTRICULAR BLOCK LONG QT SYNDROME PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA PAROXYSMAL VENTRICULAR TACHYCARDIA COMA ALTERATION OF CONSCIOUSNESS OTHER HALLUCINATIONS OTHER CONVULSIONS ALTERED MENTAL STATUS POISONING BY ANTIALLERGIC AND ANTIEMETIC DRUGS POISONING BY OPIUM (ALKALOIDS) UNSPECIFIED POISONING BY HEROIN POISONING BY METHADONE POISONING BY OTHER OPIATES AND RELATED NARCOTICS POISONING BY SALICYLATES POISONING BY AROMATIC ANALGESICS NOT ELSEWHERE CLASSIFIED POISONING BY PYRAZOLE DERIVATIVES POISONING BY PROPIONIC ACID DERIVATIVES POISONING BY HYDANTOIN DERIVATIVES POISONING BY BARBITURATES POISONING BY CHLORAL HYDRATE GROUP POISONING BY PARALDEHYDE POISONING BY BROMINE COMPOUNDS 01/01/15

14 Medicare Local Coverage Determination Policy - PA, NJ, MD, DC, DE Qualitative Drug Testing (Page 2 of 2) CPT Code: G0431, G0434 LCD Description: A qualitative drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. However, urine is the best specimen for broad qualitative screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants. ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference POISONING BY METHAQUALONE COMPOUNDS POISONING BY GLUTETHIMIDE GROUP POISONING BY MIXED SEDATIVES NOT ELSEWHERE CLASSIFIED POISONING BY OTHER SEDATIVES AND HYPNOTICS POISONING BY UNSPECIFIED SEDATIVE OR HYPNOTIC POISONING BY ANTIDEPRESSANT, UNSPECIFIED POISONING BY MONOAMINE OXIDASE INHIBITORS POISONING BY SELECTIVE SEROTONIN AND NOREPINEPHRINE REUPTAKE INHIBITORS POISONING BY SELECTIVE SEROTONIN REUPTAKE INHIBITORS POISONING BY TETRACYCLIC ANTIDEPRESSANTS POISONING BY TRICYCLIC ANTIDEPRESSANTS POISONING BY OTHER ANTIDEPRESSANTS POISONING BY PHENOTHIAZINE-BASED TRANQUILIZERS POISONING BY BUTYROPHENONE-BASED TRANQUILIZERS POISONING BY OTHER ANTIPSYCHOTICS NEUROLEPTICS AND MAJOR TRANQUILIZERS POISONING BY BENZODIAZEPINE-BASED TRANQUILIZERS POISONING BY OTHER TRANQUILIZERS POISONING BY PSYCHODYSLEPTICS (HALLUCINOGENS) POISONING BY PSYCHOSTIMULANT, UNSPECIFIED POISONING BY CAFFEINE POISONING BY AMPHETAMINES POISONING BY METHYLPHENIDATE POISONING BY OTHER PSYCHOSTIMULANTS POISONING BY OTHER SPECIFIED PSYCHOTROPIC AGENTS POISONING BY UNSPECIFIED PSYCHOTROPIC AGENT POISONING BY COCAINE POISONING BY OTHER CENTRAL NERVOUS SYSTEM STIMULANTS POISONING BY CARDIOTONIC GLYCOSIDES AND DRUGS OF SIMILAR ACTION POISONING BY UNSPECIFIED DRUG OR MEDICINAL SUBSTANCE V15.81 PERSONAL HISTORY OF NONCOMPLIANCE WITH MEDICAL TREATMENT PRESENTING HAZARDS TO HEALTH V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS 01/01/15

15 Medicare Local Coverage Determination Policy -PA, NJ, MD, DC, DE Vitamin D: 25 Hydroxy CPT Code: LCD Description: The most common type of vitamin D deficiency is that of 25 OH vitamin D. It is expected that the medical record will justify the tests chosen for a particular disease entity, that all available components of 25 OH vitamin D and other metabolite levels will not be performed routinely on every patient and that supportive documentation for test choices will be available. ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - UNSPECIFIED MILIARY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) 135 SARCOIDOSIS SECONDARY HYPERPARATHYROIDISM, NON-RENAL RICKETS ACTIVE OSTEOMALACIA UNSPECIFIED UNSPECIFIED VITAMIN D DEFICIENCY DISORDERS OF PHOSPHORUS METABOLISM HYPOCALCEMIA HYPERCALCEMIA OTHER HYPERALIMENTATION MYOPATHY IN ENDOCRINE DISEASES CLASSIFIED ELSEWHERE REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF UNSPECIFIED SITE ULCERATIVE (CHRONIC) ENTEROCOLITIS - ULCERATIVE COLITIS UNSPECIFIED ALCOHOLIC CIRRHOSIS OF LIVER CIRRHOSIS OF LIVER WITHOUT ALCOHOL BILIARY CIRRHOSIS OTHER SPECIFIED DISORDERS OF BILIARY TRACT CELIAC DISEASE - UNSPECIFIED INTESTINAL MALABSORPTION CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE OTHER PSORIASIS AND SIMILAR DISORDERS SYSTEMIC LUPUS ERYTHEMATOSUS DERMATOMYOSITIS MYALGIA AND MYOSITIS UNSPECIFIED OSTEOPOROSIS UNSPECIFIED OTHER OSTEOPOROSIS DISORDER OF BONE AND CARTILAGE UNSPECIFIED OSTEOGENESIS IMPERFECTA OSTEOPETROSIS According to Novitas Medicare, use V58.65 with to describe the current long term use of glucocorticoids and V58.69 with describe long term use of anticonvulsants and other medication known to lower Vitamin D levels. Utilization Guidelines Only one 25 OH vitamin D level will be reimbursed in any 24 hour period. Assays of vitamin D levels for conditions other than ICD 9-CM codes will be limited to once a year. Assays of the appropriate vitamin D levels for ICD-9 CM codes will be limited to 4 per year, for the previously identified deficient form of vitamin D. 09/01/14

16 Medicare Local Coverage Determination Policy - PA, NJ, MD, DC, DE Vitamin D: 1,25 Dihydroxy CPT Code: LCD Description: The most common type of vitamin D deficiency is that of 25 OH vitamin D. A much smaller percentage of 1, 25 dihydroxy vitamin D deficiency exists; mostly in those with renal disease. It is expected that the medical record will justify the tests chosen for a particular disease entity, that all available components of 25 OH vitamin D and other metabolite levels will not be performed routinely on every patient and that supportive documentation for test choices will be available to the Contractor upon request. ICD-9-CM Codes that Support Medical Necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-9-CM code. The diagnosis must be present for the procedure to be paid and the procedure must be reasonable and medically necessary for that diagnosis. Documentation within the patient s medical record must support the medical necessity for the test(s) provided. This list was compiled from the Medicare Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference PRIMARY TUBERCULOUS COMPLEX UNSPECIFIED EXAMINATION - UNSPECIFIED MILIARY TUBERCULOSIS TUBERCLE BACILLI NOT FOUND BY BACTERIOLOGICAL OR HISTOLOGICAL EXAMINATION BUT TUBERCULOSIS CONFIRMED BY OTHER METHODS (INOCULATION OF ANIMALS) 135 SARCOIDOSIS RICKETS ACTIVE OTHER HYPERALIMENTATION CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE OSTEOGENESIS IMPERFECTA OSTEOPETROSIS According to Novitas Medicare, use V58.65 with to describe the current long term use of glucocorticoids and V58.69 with describe long term use of anticonvulsants and other medication known to lower Vitamin D levels. Utilization Guidelines Only one 1,25-OH vitamin D level will be reimbursed in a 24 hour period if medically necessary. Assays of vitamin D levels for conditions other than ICD 9-CM codes will be limited to once a year. Assays of the appropriate vitamin D levels for ICD-9 CM codes will be limited to 4 per year, for the previously identified deficient form of vitamin D. 09/01/14