CMS Limitations Guide - Radiology Services

Transcription

1 CMS Limitations Guide - Radiology Services Starting October 1, 2015, CMS will update their existing medical necessity limitations on tests and procedures to correspond to ICD-10 codes. This limitations guide provides you with the latest changes. This guide is not an all-inclusive list of National Coverage Documents (NCD) and Local Coverage Documents (LCD). You can search by LCD or NCD or keyword and region on the CMS website at: CMS will deny payment if the correct diagnosis codes are not entered on the order form, and your patient s test or procedure will not be covered. We compiled this information in one location to make it easier for you to find the proper codes for medically necessary diagnoses. It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code listed below 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. We will continue to update this list as new CMS limitations are announced. You can always find the most current list at: If you have any questions, please contact Kari Smith, Office Coordinator, at (231) , or Karen Popa, Director, Patient Access Services, at (231)

2 (L35751) Non-Invasive Peripheral Venous Vascular and Hemodialysis Access Studies USV CALF REFLUX STUDY BILATERAL (93965) USV DIALYSIS GRAFT (93990) USV HEMODIALYSIS (93990) USV LOWER EXTREMITY VEIN BILATERAL (93970) USV LOWER EXTREMITY VEIN RIGHT OR LEFT (93971) USV UPPER EXTREMITY VEIN BILATERAL (93970) USV UPPER EXTREMITY VEIN RIGHT OR LEFT (93971) CPT Code Description Noninvasive physiologic studies of extremity veins, complete bilateral study (eg, Doppler Waveform analysis with responses to compression and other maneuvers, Phleborheography, Impedance Plethysmography) (USV Calf Reflux Study Bilateral) Duplex scan of extremity veins including responses to compression and other maneuvers; complete bilateral study (USV Lower Ext Vein Bilat) (USV Upper Ext Vein Bilat) Duplex scan of extremity veins including responses to compression and other maneuvers; unilateral or limited study (USV Lower Ext Vein RT or LT) (USV Upper Ext Vein RT or LT) Duplex scan of hemodialysis access (including arterial inflow, body of access and venous outflow) (USV Dialysis Graft) (USV Hemodialysis) G0365 Vessel mapping of vessels for hemodialysis access (services for preoperative vessel mapping prior to creation of hemodialysis access using an autogenous hemodialysis conduit, including arterial inflow and venous outflow) ICD-10 Codes That Support Medical Necessity and Covered by Medicare Program: Group 1 Paragraph: Peripheral Venous Examinations (93965, 93970, and 93971) Group 1 Codes: Code Description D68.51 Activated protein C resistance D68.52 Prothrombin gene mutation D68.59 Other primary thrombophilia D68.61 Antiphospholipid syndrome D68.62 Lupus anticoagulant syndrome D68.69 Other thrombophilia D75.81 Myelofibrosis D75.82 Heparin induced thrombocytopenia (HIT) D75.89 Other specified diseases of blood and blood-forming organs I26.01 Septic pulmonary embolism with acute cor pulmonale I26.02 Saddle embolus of pulmonary artery with acute cor pulmonale I26.09 Other pulmonary embolism with acute cor pulmonale I26.90 Septic pulmonary embolism without acute cor pulmonale

3 I26.92 Saddle embolus of pulmonary artery without acute cor pulmonale I26.99 Other pulmonary embolism without acute cor pulmonale I27.82 Chronic pulmonary embolism I80.01 Phlebitis and thrombophlebitis of superficial vessels of right lower extremity I80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity I80.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral I80.11 Phlebitis and thrombophlebitis of right femoral vein I80.12 Phlebitis and thrombophlebitis of left femoral vein I80.13 Phlebitis and thrombophlebitis of femoral vein, bilateral I Phlebitis and thrombophlebitis of right iliac vein I Phlebitis and thrombophlebitis of left iliac vein I Phlebitis and thrombophlebitis of iliac vein, bilateral I Phlebitis and thrombophlebitis of right popliteal vein I Phlebitis and thrombophlebitis of left popliteal vein I Phlebitis and thrombophlebitis of popliteal vein, bilateral I Phlebitis and thrombophlebitis of right tibial vein I Phlebitis and thrombophlebitis of left tibial vein I Phlebitis and thrombophlebitis of tibial vein, bilateral I Phlebitis and thrombophlebitis of other deep vessels of right lower extremity I Phlebitis and thrombophlebitis of other deep vessels of left lower extremity I Phlebitis and thrombophlebitis of other deep vessels of lower extremity, bilateral I80.8 Phlebitis and thrombophlebitis of other sites I82.1 Thrombophlebitis migrans I Acute embolism and thrombosis of superior vena cava I Chronic embolism and thrombosis of superior vena cava I Acute embolism and thrombosis of other thoracic veins I Chronic embolism and thrombosis of other thoracic veins I Acute embolism and thrombosis of right femoral vein I Acute embolism and thrombosis of left femoral vein I Acute embolism and thrombosis of femoral vein, bilateral I Acute embolism and thrombosis of right iliac vein I Acute embolism and thrombosis of left iliac vein I Acute embolism and thrombosis of iliac vein, bilateral I Acute embolism and thrombosis of right popliteal vein I Acute embolism and thrombosis of left popliteal vein I Acute embolism and thrombosis of popliteal vein, bilateral I Acute embolism and thrombosis of right tibial vein

4 I Acute embolism and thrombosis of left tibial vein I Acute embolism and thrombosis of tibial vein, bilateral I Acute embolism and thrombosis of other specified deep vein of right lower extremity I Acute embolism and thrombosis of other specified deep vein of left lower extremity I Acute embolism and thrombosis of other specified deep vein of lower extremity, bilateral I Chronic embolism and thrombosis of right femoral vein I Chronic embolism and thrombosis of left femoral vein I Chronic embolism and thrombosis of femoral vein, bilateral I Chronic embolism and thrombosis of right iliac vein I Chronic embolism and thrombosis of left iliac vein I Chronic embolism and thrombosis of iliac vein, bilateral I Chronic embolism and thrombosis of right popliteal vein I Chronic embolism and thrombosis of left popliteal vein I Chronic embolism and thrombosis of popliteal vein, bilateral I Chronic embolism and thrombosis of right tibial vein I Chronic embolism and thrombosis of left tibial vein I Chronic embolism and thrombosis of tibial vein, bilateral I Chronic embolism and thrombosis of other specified deep vein of right lower extremity I Chronic embolism and thrombosis of other specified deep vein of left lower extremity I Chronic embolism and thrombosis of other specified deep vein of lower extremity, bilateral I Acute embolism and thrombosis of superficial veins of right upper extremity I Acute embolism and thrombosis of superficial veins of left upper extremity I Acute embolism and thrombosis of superficial veins of upper extremity, bilateral I Acute embolism and thrombosis of deep veins of right upper extremity I Acute embolism and thrombosis of deep veins of left upper extremity I Acute embolism and thrombosis of deep veins of upper extremity, bilateral I Chronic embolism and thrombosis of superficial veins of right upper extremity I Chronic embolism and thrombosis of superficial veins of left upper extremity I Chronic embolism and thrombosis of superficial veins of upper extremity, bilateral I Chronic embolism and thrombosis of deep veins of right upper extremity I Chronic embolism and thrombosis of deep veins of left upper extremity I Chronic embolism and thrombosis of deep veins of upper extremity, bilateral I82.A11 I82.A12 I82.A13 I82.A21 I82.A22 Acute embolism and thrombosis of right axillary vein Acute embolism and thrombosis of left axillary vein Acute embolism and thrombosis of axillary vein, bilateral Chronic embolism and thrombosis of right axillary vein Chronic embolism and thrombosis of left axillary vein

5 I82.A23 Chronic embolism and thrombosis of axillary vein, bilateral I82.B11 Acute embolism and thrombosis of right subclavian vein I82.B12 Acute embolism and thrombosis of left subclavian vein I82.B13 Acute embolism and thrombosis of subclavian vein, bilateral I82.B21 Chronic embolism and thrombosis of right subclavian vein I82.B22 Chronic embolism and thrombosis of left subclavian vein I82.B23 Chronic embolism and thrombosis of subclavian vein, bilateral I82.C11 Acute embolism and thrombosis of right internal jugular vein I82.C12 Acute embolism and thrombosis of left internal jugular vein I82.C13 Acute embolism and thrombosis of internal jugular vein, bilateral I82.C21 Chronic embolism and thrombosis of right internal jugular vein I82.C22 Chronic embolism and thrombosis of left internal jugular vein I82.C23 Chronic embolism and thrombosis of internal jugular vein, bilateral I Embolism and thrombosis of superficial veins of right lower extremities I Embolism and thrombosis of superficial veins of left lower extremities I Embolism and thrombosis of superficial veins of lower extremities, bilateral I Acute embolism and thrombosis of other specified veins I Chronic embolism and thrombosis of other specified veins I Varicose veins of right lower extremity with ulcer of thigh I Varicose veins of right lower extremity with ulcer of calf I Varicose veins of right lower extremity with ulcer of ankle I Varicose veins of right lower extremity with ulcer of heel and midfoot I Varicose veins of right lower extremity with ulcer other part of foot I Varicose veins of right lower extremity with ulcer other part of lower leg I Varicose veins of left lower extremity with ulcer of thigh I Varicose veins of left lower extremity with ulcer of calf I Varicose veins of left lower extremity with ulcer of ankle I Varicose veins of left lower extremity with ulcer of heel and midfoot I Varicose veins of left lower extremity with ulcer other part of foot I Varicose veins of left lower extremity with ulcer other part of lower leg I83.11 Varicose veins of right lower extremity with inflammation I83.12 Varicose veins of left lower extremity with inflammation I Varicose veins of right lower extremity with both ulcer of thigh and inflammation I Varicose veins of right lower extremity with both ulcer of calf and inflammation I Varicose veins of right lower extremity with both ulcer of ankle and inflammation I Varicose veins of right lower extremity with both ulcer of heel and midfoot and inflammation I Varicose veins of right lower extremity with both ulcer other part of foot and inflammation

6 I Varicose veins of right lower extremity with both ulcer of other part of lower extremity and inflammation I Varicose veins of left lower extremity with both ulcer of thigh and inflammation I Varicose veins of left lower extremity with both ulcer of calf and inflammation I Varicose veins of left lower extremity with both ulcer of ankle and inflammation I Varicose veins of left lower extremity with both ulcer of heel and midfoot and inflammation I Varicose veins of left lower extremity with both ulcer other part of foot and inflammation I Varicose veins of left lower extremity with both ulcer of other part of lower extremity and inflammation I Varicose veins of right lower extremities with pain I Varicose veins of left lower extremities with pain I Varicose veins of bilateral lower extremities with pain I Varicose veins of right lower extremities with other complications I Varicose veins of left lower extremities with other complications I Varicose veins of bilateral lower extremities with other complications I83.91 Asymptomatic varicose veins of right lower extremity I83.92 Asymptomatic varicose veins of left lower extremity I83.93 Asymptomatic varicose veins of bilateral lower extremities I Postthrombotic syndrome without complications of right lower extremity I Postthrombotic syndrome without complications of left lower extremity I Postthrombotic syndrome without complications of bilateral lower extremity I Postthrombotic syndrome with ulcer of right lower extremity I Postthrombotic syndrome with ulcer of left lower extremity I Postthrombotic syndrome with ulcer of bilateral lower extremity I Postthrombotic syndrome with inflammation of right lower extremity I Postthrombotic syndrome with inflammation of left lower extremity I Postthrombotic syndrome with inflammation of bilateral lower extremity I Postthrombotic syndrome with ulcer and inflammation of right lower extremity I Postthrombotic syndrome with ulcer and inflammation of left lower extremity I Postthrombotic syndrome with ulcer and inflammation of bilateral lower extremity I Postthrombotic syndrome with other complications of right lower extremity I Postthrombotic syndrome with other complications of left lower extremity I Postthrombotic syndrome with other complications of bilateral lower extremity I87.1 Compression of vein I87.2 Venous insufficiency (chronic) (peripheral) I Chronic venous hypertension (idiopathic) without complications of right lower extremity I Chronic venous hypertension (idiopathic) without complications of left lower extremity I Chronic venous hypertension (idiopathic) without complications of bilateral lower extremity

7 I Chronic venous hypertension (idiopathic) with ulcer of right lower extremity I Chronic venous hypertension (idiopathic) with ulcer of left lower extremity I Chronic venous hypertension (idiopathic) with ulcer of bilateral lower extremity I Chronic venous hypertension (idiopathic) with inflammation of right lower extremity I Chronic venous hypertension (idiopathic) with inflammation of left lower extremity I Chronic venous hypertension (idiopathic) with inflammation of bilateral lower extremity I Chronic venous hypertension (idiopathic) with ulcer and inflammation of right lower extremity I Chronic venous hypertension (idiopathic) with ulcer and inflammation of left lower extremity I Chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity I Chronic venous hypertension (idiopathic) with other complications of right lower extremity I Chronic venous hypertension (idiopathic) with other complications of left lower extremity I Chronic venous hypertension (idiopathic) with other complications of bilateral lower extremity I87.8 Other specified disorders of veins I96 Gangrene, not elsewhere classified I Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating a cardiac catheterization I Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating a cardiac bypass I Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating other circulatory system procedure I97.42 Intraoperative hemorrhage and hematoma of a circulatory system organ or structure complicating other procedure I97.51 Accidental puncture and laceration of a circulatory system organ or structure during a circulatory system procedure I97.52 Accidental puncture and laceration of a circulatory system organ or structure during other procedure I Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following a cardiac catheterization I Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following cardiac bypass I Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following other circulatory system procedure I97.62 Postprocedural hemorrhage and hematoma of a circulatory system organ or structure following other procedure J96.01 Acute respiratory failure with hypoxia J96.02 Acute respiratory failure with hypercapnia L76.01 Intraoperative hemorrhage and hematoma of skin and subcutaneous tissue complicating a dermatologic procedure L76.02 Intraoperative hemorrhage and hematoma of skin and subcutaneous tissue complicating other procedure L76.11 Accidental puncture and laceration of skin and subcutaneous tissue during a dermatologic procedure L76.12 Accidental puncture and laceration of skin and subcutaneous tissue during other procedure L76.21 Postprocedural hemorrhage and hematoma of skin and subcutaneous tissue following a dermatologic procedure L76.22 Postprocedural hemorrhage and hematoma of skin and subcutaneous tissue following other

8 procedure L Non-pressure chronic ulcer of right thigh limited to breakdown of skin L Non-pressure chronic ulcer of right thigh with fat layer exposed L Non-pressure chronic ulcer of right thigh with necrosis of muscle L Non-pressure chronic ulcer of right thigh with necrosis of bone L Non-pressure chronic ulcer of left thigh limited to breakdown of skin L Non-pressure chronic ulcer of left thigh with fat layer exposed L Non-pressure chronic ulcer of left thigh with necrosis of muscle L Non-pressure chronic ulcer of left thigh with necrosis of bone L Non-pressure chronic ulcer of right calf limited to breakdown of skin L Non-pressure chronic ulcer of right calf with fat layer exposed L Non-pressure chronic ulcer of right calf with necrosis of muscle L Non-pressure chronic ulcer of right calf with necrosis of bone L Non-pressure chronic ulcer of left calf limited to breakdown of skin L Non-pressure chronic ulcer of left calf with fat layer exposed L Non-pressure chronic ulcer of left calf with necrosis of muscle L Non-pressure chronic ulcer of left calf with necrosis of bone L Non-pressure chronic ulcer of right ankle limited to breakdown of skin L Non-pressure chronic ulcer of right ankle with fat layer exposed L Non-pressure chronic ulcer of right ankle with necrosis of muscle L Non-pressure chronic ulcer of right ankle with necrosis of bone L Non-pressure chronic ulcer of left ankle limited to breakdown of skin L Non-pressure chronic ulcer of left ankle with fat layer exposed L Non-pressure chronic ulcer of left ankle with necrosis of muscle L Non-pressure chronic ulcer of left ankle with necrosis of bone L Non-pressure chronic ulcer of right heel and midfoot limited to breakdown of skin L Non-pressure chronic ulcer of right heel and midfoot with fat layer exposed L Non-pressure chronic ulcer of right heel and midfoot with necrosis of muscle L Non-pressure chronic ulcer of right heel and midfoot with necrosis of bone L Non-pressure chronic ulcer of left heel and midfoot limited to breakdown of skin L Non-pressure chronic ulcer of left heel and midfoot with fat layer exposed L Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle L Non-pressure chronic ulcer of left heel and midfoot with necrosis of bone L Non-pressure chronic ulcer of other part of right foot limited to breakdown of skin L Non-pressure chronic ulcer of other part of right foot with fat layer exposed L Non-pressure chronic ulcer of other part of right foot with necrosis of muscle L Non-pressure chronic ulcer of other part of right foot with necrosis of bone

9 L Non-pressure chronic ulcer of other part of left foot limited to breakdown of skin L Non-pressure chronic ulcer of other part of left foot with fat layer exposed L Non-pressure chronic ulcer of other part of left foot with necrosis of muscle L Non-pressure chronic ulcer of other part of left foot with necrosis of bone L Non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin L Non-pressure chronic ulcer of other part of right lower leg with fat layer exposed L Non-pressure chronic ulcer of other part of right lower leg with necrosis of muscle L Non-pressure chronic ulcer of other part of right lower leg with necrosis of bone L Non-pressure chronic ulcer of other part of left lower leg limited to breakdown of skin L Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed L Non-pressure chronic ulcer of other part of left lower leg with necrosis of muscle L Non-pressure chronic ulcer of other part of left lower leg with necrosis of bone M Pain in right arm M Pain in left arm M Pain in right leg M Pain in left leg M Pain in right upper arm M Pain in left upper arm M Pain in right forearm M Pain in left forearm M Pain in right hand M Pain in left hand M Pain in right thigh M Pain in left thigh M Pain in right lower leg M Pain in left lower leg M Pain in right foot M Pain in left foot M Intraoperative hemorrhage and hematoma of a musculoskeletal structure complicating a musculoskeletal system procedure M Intraoperative hemorrhage and hematoma of a musculoskeletal structure complicating other procedure M Accidental puncture and laceration of a musculoskeletal structure during a musculoskeletal system procedure M Accidental puncture and laceration of a musculoskeletal structure during other procedure M Postprocedural hemorrhage and hematoma of a musculoskeletal structure following a musculoskeletal system procedure M Postprocedural hemorrhage and hematoma of a musculoskeletal structure following other procedure O22.01 Varicose veins of lower extremity in pregnancy, first trimester

10 O22.02 Varicose veins of lower extremity in pregnancy, second trimester O22.03 Varicose veins of lower extremity in pregnancy, third trimester O22.11 Genital varices in pregnancy, first trimester O22.12 Genital varices in pregnancy, second trimester O22.13 Genital varices in pregnancy, third trimester O22.21 Superficial thrombophlebitis in pregnancy, first trimester O22.22 Superficial thrombophlebitis in pregnancy, second trimester O22.23 Superficial thrombophlebitis in pregnancy, third trimester O22.31 Deep phlebothrombosis in pregnancy, first trimester O22.32 Deep phlebothrombosis in pregnancy, second trimester O22.33 Deep phlebothrombosis in pregnancy, third trimester O86.81 Puerperal septic thrombophlebitis O87.0 Superficial thrombophlebitis in the puerperium O87.4 Varicose veins of lower extremity in the puerperium Q27.31 Arteriovenous malformation of vessel of upper limb Q27.32 Arteriovenous malformation of vessel of lower limb Q27.39 Arteriovenous malformation, other site Q27.8 Other specified congenital malformations of peripheral vascular system R04.2 Hemoptysis R04.89 Hemorrhage from other sites in respiratory passages R06.02 Shortness of breath R07.1 Chest pain on breathing R07.89 Other chest pain R09.02 Hypoxemia R22.31 Localized swelling, mass and lump, right upper limb R22.32 Localized swelling, mass and lump, left upper limb R22.33 Localized swelling, mass and lump, upper limb, bilateral R22.41 Localized swelling, mass and lump, right lower limb R22.42 Localized swelling, mass and lump, left lower limb R22.43 Localized swelling, mass and lump, lower limb, bilateral R60.0 Localized edema S35.514D S35.515D S35.59XD S45.211A S45.211D S45.212A Injury of right iliac vein, subsequent Injury of left iliac vein, subsequent Injury of other iliac blood vessels, subsequent Laceration of axillary or brachial vein, right side, initial Laceration of axillary or brachial vein, right side, subsequent Laceration of axillary or brachial vein, left side, initial

11 S45.212D S45.291A S45.291D S45.292A S45.292D S45.311A S45.311D S45.312A S45.312D S45.391A S45.391D S45.392A S45.392D S55.211A S55.211D S55.212A S55.212D S55.291A S55.291D S55.292A S55.292D S75.111A S75.111D S75.112A S75.112D S75.121A S75.121D S75.122A S75.122D S75.191A S75.191D S75.192A S75.192D S75.211A S75.211D Laceration of axillary or brachial vein, left side, subsequent Other specified injury of axillary or brachial vein, right side, initial Other specified injury of axillary or brachial vein, right side, subsequent Other specified injury of axillary or brachial vein, left side, initial Other specified injury of axillary or brachial vein, left side, subsequent Laceration of superficial vein at shoulder and upper arm level, right arm, initial Laceration of superficial vein at shoulder and upper arm level, right arm, subsequent Laceration of superficial vein at shoulder and upper arm level, left arm, initial Laceration of superficial vein at shoulder and upper arm level, left arm, subsequent Other specified injury of superficial vein at shoulder and upper arm level, right arm, initial Other specified injury of superficial vein at shoulder and upper arm level, right arm, subsequent Other specified injury of superficial vein at shoulder and upper arm level, left arm, initial Other specified injury of superficial vein at shoulder and upper arm level, left arm, subsequent Laceration of vein at forearm level, right arm, initial Laceration of vein at forearm level, right arm, subsequent Laceration of vein at forearm level, left arm, initial Laceration of vein at forearm level, left arm, subsequent Other specified injury of vein at forearm level, right arm, initial Other specified injury of vein at forearm level, right arm, subsequent Other specified injury of vein at forearm level, left arm, initial Other specified injury of vein at forearm level, left arm, subsequent Minor laceration of femoral vein at hip and thigh level, right leg, initial Minor laceration of femoral vein at hip and thigh level, right leg, subsequent Minor laceration of femoral vein at hip and thigh level, left leg, initial Minor laceration of femoral vein at hip and thigh level, left leg, subsequent Major laceration of femoral vein at hip and thigh level, right leg, initial Major laceration of femoral vein at hip and thigh level, right leg, subsequent Major laceration of femoral vein at hip and thigh level, left leg, initial Major laceration of femoral vein at hip and thigh level, left leg, subsequent Other specified injury of femoral vein at hip and thigh level, right leg, initial Other specified injury of femoral vein at hip and thigh level, right leg, subsequent Other specified injury of femoral vein at hip and thigh level, left leg, initial Other specified injury of femoral vein at hip and thigh level, left leg, subsequent Minor laceration of greater saphenous vein at hip and thigh level, right leg, initial Minor laceration of greater saphenous vein at hip and thigh level, right leg, subsequent

12 S75.212A S75.212D S75.221A S75.221D S75.222A S75.222D S75.291A S75.291D S75.292A S75.292D S85.311A S85.311D S85.312A S85.312D S85.391A S85.391D S85.392A S85.392D S85.411A S85.411D S85.412A S85.412D S85.491A S85.491D S85.492A S85.492D S85.511A S85.511D S85.512A S85.512D S85.591A S85.591D S85.592A S85.592D S95.211A Minor laceration of greater saphenous vein at hip and thigh level, left leg, initial Minor laceration of greater saphenous vein at hip and thigh level, left leg, subsequent Major laceration of greater saphenous vein at hip and thigh level, right leg, initial Major laceration of greater saphenous vein at hip and thigh level, right leg, subsequent Major laceration of greater saphenous vein at hip and thigh level, left leg, initial Major laceration of greater saphenous vein at hip and thigh level, left leg, subsequent Other specified injury of greater saphenous vein at hip and thigh level, right leg, initial Other specified injury of greater saphenous vein at hip and thigh level, right leg, subsequent Other specified injury of greater saphenous vein at hip and thigh level, left leg, initial Other specified injury of greater saphenous vein at hip and thigh level, left leg, subsequent Laceration of greater saphenous vein at lower leg level, right leg, initial Laceration of greater saphenous vein at lower leg level, right leg, subsequent Laceration of greater saphenous vein at lower leg level, left leg, initial Laceration of greater saphenous vein at lower leg level, left leg, subsequent Other specified injury of greater saphenous vein at lower leg level, right leg, initial Other specified injury of greater saphenous vein at lower leg level, right leg, subsequent Other specified injury of greater saphenous vein at lower leg level, left leg, initial Other specified injury of greater saphenous vein at lower leg level, left leg, subsequent Laceration of lesser saphenous vein at lower leg level, right leg, initial Laceration of lesser saphenous vein at lower leg level, right leg, subsequent Laceration of lesser saphenous vein at lower leg level, left leg, initial Laceration of lesser saphenous vein at lower leg level, left leg, subsequent Other specified injury of lesser saphenous vein at lower leg level, right leg, initial Other specified injury of lesser saphenous vein at lower leg level, right leg, subsequent Other specified injury of lesser saphenous vein at lower leg level, left leg, initial Other specified injury of lesser saphenous vein at lower leg level, left leg, subsequent Laceration of popliteal vein, right leg, initial Laceration of popliteal vein, right leg, subsequent Laceration of popliteal vein, left leg, initial Laceration of popliteal vein, left leg, subsequent Other specified injury of popliteal vein, right leg, initial Other specified injury of popliteal vein, right leg, subsequent Other specified injury of popliteal vein, left leg, initial Other specified injury of popliteal vein, left leg, subsequent Laceration of dorsal vein of right foot, initial

13 S95.211D S95.212A S95.212D S95.291A S95.291D S95.292A S95.292D T38.4X5D T38.5X5D T45.7X5D T79.0XXD T79.1XXD T79.A11D T79.A12D T79.A21D T79.A22D T79.A3XD T79.A9XD T80.0XXA T80.0XXD T80.1XXA T80.1XXD T80.810D T80.818D T80.89XD T81.31XD T81.32XD T81.33XD T81.4XXD T82.318A T82.318D T82.328A T82.328D T82.338A T82.338D Laceration of dorsal vein of right foot, subsequent Laceration of dorsal vein of left foot, initial Laceration of dorsal vein of left foot, subsequent Other specified injury of dorsal vein of right foot, initial Other specified injury of dorsal vein of right foot, subsequent Other specified injury of dorsal vein of left foot, initial Other specified injury of dorsal vein of left foot, subsequent Adverse effect of oral contraceptives, subsequent Adverse effect of other estrogens and progestogens, subsequent Adverse effect of anticoagulant antagonists, vitamin K and other coagulants, subsequent Air embolism (traumatic), subsequent Fat embolism (traumatic), subsequent Traumatic compartment syndrome of right upper extremity, subsequent Traumatic compartment syndrome of left upper extremity, subsequent Traumatic compartment syndrome of right lower extremity, subsequent Traumatic compartment syndrome of left lower extremity, subsequent Traumatic compartment syndrome of abdomen, subsequent Traumatic compartment syndrome of other sites, subsequent Air embolism following infusion, transfusion and therapeutic injection, initial Air embolism following infusion, transfusion and therapeutic injection, subsequent Vascular complications following infusion, transfusion and therapeutic injection, initial Vascular complications following infusion, transfusion and therapeutic injection, subsequent Extravasation of vesicant antineoplastic chemotherapy, subsequent Extravasation of other vesicant agent, subsequent Other complications following infusion, transfusion and therapeutic injection, subsequent Disruption of external operation (surgical) wound, not elsewhere classified, subsequent Disruption of internal operation (surgical) wound, not elsewhere classified, subsequent Disruption of traumatic injury wound repair, subsequent Infection following a procedure, subsequent Breakdown (mechanical) of other vascular grafts, initial Breakdown (mechanical) of other vascular grafts, subsequent Displacement of other vascular grafts, initial Displacement of other vascular grafts, subsequent Leakage of other vascular grafts, initial Leakage of other vascular grafts, subsequent

14 T82.398A T82.398D T82.41XA T82.41XD T82.42XA T82.42XD T82.43XA T82.43XD T82.49XA T82.49XD T82.510A T82.510D T82.511A T82.511D T82.520A T82.520D T82.521A T82.521D T82.523A T82.523D T82.524A T82.524D T82.525A T82.525D T82.528A T82.528D T82.530A T82.530D T82.531A T82.531D T82.817A T82.817D T82.818A T82.818D T82.858A T82.858D T82.867D Other mechanical complication of other vascular grafts, initial Other mechanical complication of other vascular grafts, subsequent Breakdown (mechanical) of vascular dialysis catheter, initial Breakdown (mechanical) of vascular dialysis catheter, subsequent Displacement of vascular dialysis catheter, initial Displacement of vascular dialysis catheter, subsequent Leakage of vascular dialysis catheter, initial Leakage of vascular dialysis catheter, subsequent Other complication of vascular dialysis catheter, initial Other complication of vascular dialysis catheter, subsequent Breakdown (mechanical) of surgically created arteriovenous fistula, initial Breakdown (mechanical) of surgically created arteriovenous fistula, subsequent Breakdown (mechanical) of surgically created arteriovenous shunt, initial Breakdown (mechanical) of surgically created arteriovenous shunt, subsequent Displacement of surgically created arteriovenous fistula, initial Displacement of surgically created arteriovenous fistula, subsequent Displacement of surgically created arteriovenous shunt, initial Displacement of surgically created arteriovenous shunt, subsequent Displacement of balloon (counterpulsation) device, initial Displacement of balloon (counterpulsation) device, subsequent Displacement of infusion catheter, initial Displacement of infusion catheter, subsequent Displacement of umbrella device, initial Displacement of umbrella device, subsequent Displacement of other cardiac and vascular devices and implants, initial Displacement of other cardiac and vascular devices and implants, subsequent Leakage of surgically created arteriovenous fistula, initial Leakage of surgically created arteriovenous fistula, subsequent Leakage of surgically created arteriovenous shunt, initial Leakage of surgically created arteriovenous shunt, subsequent Embolism of cardiac prosthetic devices, implants and grafts, initial Embolism of cardiac prosthetic devices, implants and grafts, subsequent Embolism of vascular prosthetic devices, implants and grafts, initial Embolism of vascular prosthetic devices, implants and grafts, subsequent Stenosis of vascular prosthetic devices, implants and grafts, initial Stenosis of vascular prosthetic devices, implants and grafts, subsequent Thrombosis of cardiac prosthetic devices, implants and grafts, subsequent

15 T82.868A T82.868D Thrombosis of vascular prosthetic devices, implants and grafts, initial Thrombosis of vascular prosthetic devices, implants and grafts, subsequent T85.81XD Embolism due to internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent T85.86XD Thrombosis due to internal prosthetic devices, implants and grafts, not elsewhere classified, subsequent Z Encounter for other preprocedural examination Z Personal history of pulmonary embolism Z Personal history of other venous thrombosis and embolism Z86.72 Personal history of thrombophlebitis Z86.74 Personal history of sudden cardiac arrest Group 2 Paragraph: Hemodialysis Access Examination (93990) For codes in the table below that require a 7th character, letter A initial, D subsequent or S sequela may be used. Group 2 Codes: Code Description I77.0 Arteriovenous fistula, acquired N18.6 End stage renal disease T82.41XA T82.42XA T82.43XA T82.49XA T82.510A T82.520A T82.530A T82.590A T82.7XXA T82.818A T82.828A T82.838A T82.848A T82.858A T82.868A Breakdown (mechanical) of vascular dialysis catheter, initial Displacement of vascular dialysis catheter, initial Leakage of vascular dialysis catheter, initial Other complication of vascular dialysis catheter, initial Breakdown (mechanical) of surgically created arteriovenous fistula, initial Displacement of surgically created arteriovenous fistula, initial Leakage of surgically created arteriovenous fistula, initial Other mechanical complication of surgically created arteriovenous fistula, initial Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial Embolism of vascular prosthetic devices, implants and grafts, initial Fibrosis of vascular prosthetic devices, implants and grafts, initial Hemorrhage of vascular prosthetic devices, implants and grafts, initial Pain from vascular prosthetic devices, implants and grafts, initial Stenosis of vascular prosthetic devices, implants and grafts, initial Thrombosis of vascular prosthetic devices, implants and grafts, initial T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initial Z99.2 Dependence on renal dialysis

16 Group 3 Paragraph: Vessel Mapping for Vessels for Hemodialysis Access (G0365) Pre-operative examination for potential harvest vein grafts or pre-operative examination of vessel prior to hemodialysis access surgery Z For codes in the table below that require a 7th character, letter A initial, D subsequent or S sequela may be used. Group 3 Codes: Code Description I74.2 Embolism and thrombosis of arteries of the upper extremities N18.4 Chronic kidney disease, stage 4 (severe) N18.5 Chronic kidney disease, stage 5 N18.6 End stage renal disease T82.42XA T82.43XA T82.49XA T82.510A T82.511A T82.520A T82.530A T82.590A T82.7XXA T82.818A T82.828A T82.838A T82.848A T82.858A T82.868A Displacement of vascular dialysis catheter, initial Leakage of vascular dialysis catheter, initial Other complication of vascular dialysis catheter, initial Breakdown (mechanical) of surgically created arteriovenous fistula, initial Breakdown (mechanical) of surgically created arteriovenous shunt, initial Displacement of surgically created arteriovenous fistula, initial Leakage of surgically created arteriovenous fistula, initial Other mechanical complication of surgically created arteriovenous fistula, initial Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial Embolism of vascular prosthetic devices, implants and grafts, initial Fibrosis of vascular prosthetic devices, implants and grafts, initial Hemorrhage of vascular prosthetic devices, implants and grafts, initial Pain from vascular prosthetic devices, implants and grafts, initial Stenosis of vascular prosthetic devices, implants and grafts, initial Thrombosis of vascular prosthetic devices, implants and grafts, initial T82.898A Other specified complication of vascular prosthetic devices, implants and grafts, initial Z Encounter for other preprocedural examination