Medicare National and Local Coverage Determination Policy LA 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. Please note this document has been updated with National Medicare changes effective 7/1/2015 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 27.29 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 LA Allergy Testing Assays for Vitamins and Metabolic Function Blood Folic Acid Serum Assays for Vitamins and Metabolic Function C-Reactive Protein HS Assays for Vitamins and Metabolic Function Carnitine Assays for Vitamins and Metabolic Function Cell Function Assay with Stimulation and Lymphocyte Transformation Assays for Vitamins and Metabolic Function Fibrinogen Assays for Vitamins and Metabolic Function Homocysteine Assays for Vitamins and Metabolic Function Assay Lipoprotein PLA2 Assays for Vitamins and Metabolic Function Vitamin B-6 Assays for Vitamins and Metabolic Function Vitamin B 12 Assays for Vitamins and Metabolic Function Vitamin D 1, 25-dihydroxy Assays for Vitamins and Metabolic Function Vitamin D, 25-hydroxy (Includes Fractions, If Performed) Assays for Vitamins and Metabolic Function - Non-Covered Tests\Frequency Biomarkers for Oncology Biomarkers Overview Flow Cytometry Frequency of Laboratory Tests Glucose Testing Frequency of Laboratory Tests Lipids Frequency of Laboratory Tests Thyroid Testing Molecular Diagnostics: Genitouriinary Infectious Disease Testing Qualitative Drug Screening Services That Are Not Reasonable and Necessary QuestDiagnostics.com 08/13/2015
L35771 Allergy Testing (Page 1 of 3) CPT Code: 82785, 86003 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 CPTs 82785 AND 86003 117.3 Aspergillosis 691.8 Other Atopic Dermatitis And Related Conditions 708.0 Allergic Urticaria 708.3 Dermatographic Urticaria 989.5 Toxic Effect Of Venom 989.82 Toxic Effect Of Latex 995.0 OTHER ANAPHYLACTIC Reaction 995.60 Anaphylactic Reaction Due To Unspecified Food 995.61 Anaphylactic Reaction Due To Peanuts 995.62 Anaphylactic Reaction Due To Crustaceans 995.63 Anaphylactic Reaction Due To Fruits And Vegetables 995.64 Anaphylactic Reaction Due To Tree Nuts And Seeds 995.65 Anaphylactic Reaction Due To Fish 995.66 Anaphylactic Reaction Due To Food Additives 995.67 Anaphylactic Reaction Due To Milk Products 995.68 Anaphylactic Reaction Due To Eggs 995.69 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. 08/13/15
L35771 Allergy Testing (Page 2 of 3) CPT Code: 82785, 86003 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. 372.00 Acute Conjunctivitis Unspecified 372.05 Acute Atopic Conjunctivitis 372.13 Vernal Conjunctivitis 372.14 Other Chronic Allergic Conjunctivitis 381.01 Acute Serous Otitis Media 381.3 Other And Unspecified Chronic Nonsuppurative Otitis Media 382.9 Unspecified Otitis Media 461.0 Acute Maxillary Sinusitis 461.1 Acute Frontal Sinusitis 461.2 Acute Ethmoidal Sinusitis 461.3 Acute Sphenoidal Sinusitis 461.8 Other Acute Sinusitis 461.9 Acute Sinusitis Unspecified 462 Acute Pharyngitis 463 Acute Tonsillitis 464.00 Acute Laryngitis Without Obstruction 464.01 Acute Laryngitis With Obstruction 464.50 Supraglottitis Unspecified Without Obstruction 464.51 Supraglottitis Unspecified With Obstruction 466.0 Acute Bronchitis 471.0 Polyp Of Nasal Cavity 471.8 Other Polyp Of Sinus 471.9 Unspecified Nasal Polyp 473.0 Chronic Maxillary Sinusitis 473.1 Chronic Frontal Sinusitis FOR CPT 86003 ONLY 473.2 Chronic Ethmoidal Sinusitis 477.0 Allergic Rhinitis Due To Pollen 477.8 Allergic Rhinitis Due To Other Allergen 477.9 Allergic Rhinitis Cause Unspecified 478.0 Hypertrophy Of Nasal Turbinates 478.19 Other Disease Of Nasal Cavity And Sinuses 493.00 Extrinsic Asthma Unspecified 493.01 Extrinsic Asthma With Status Asthmaticus 493.02 Extrinsic Asthma With (Acute) Exacerbation 493.10 Intrinsic Asthma Unspecified 493.11 Intrinsic Asthma With Status Asthmaticus 493.12 Intrinsic Asthma With (Acute) Exacerbation 493.20 Chronic Obstructive Asthma Unspecified 493.21 Chronic Obstructive Asthma With Status Asthmaticus 493.22 Chronic Obstructive Asthma With (Acute) Exacerbation 493.81 Exercise-induced Bronchospasm 493.82 Cough Variant Asthma 493.90 Asthma Unspecified 493.91 Asthma Unspecified Type With Status Asthmaticus 493.92 Asthma Unspecified With (Acute) Exacerb 535.40 Other Specified Gastritis (Without Hemorrhage) 691.8 Other Atopic Dermatitis And Related Conditions 693.1 Dermatitis Due To Food Taken Internally 698.9 Unspecified Pruritic Disorder 708.0 Allergic Urticaria 08/13/15
L35771 Allergy Testing (Page 3 of 3) CPT Code: 82785, 86003 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 86003 ONLY 708.1 Idiopathic Urticaria 708.8 Other Specified Urticaria 708.9 Unspecified Urticaria 786.09 Respiratory Abnormality Other 786.2 Cough 989.5 Toxic Effect Of Venom 995.0 Other Anaphylactic Reaction 995.1 Angioneurotic Edema Not Elsewhere Classified 995.20 Unspecified Adverse Effect Of Unspecified Drug, Medicinal And Biological Substance 995.27 Other Drug Allergy 995.29 Unspecified Adverse Effect Of Other Drug, Medicinal And Biological Substance 995.3 Allergy Unspecified Not Elsewhere Classified 999.41 Anaphylactic Reaction Due To Administration Of Blood And Blood Products 999.42 Anaphylactic Reaction Due To Vaccination 999.49 Anaphylactic Reaction Due To Other Serum 999.51 Other Serum Reaction Due To Administration Of Blood And Blood Products 999.52 Other Serum Reaction Due To Vaccination 999.59 Other Serum Reaction V14.0 Personal History Of Allergy To Penicillin V14.1 Personal History Of Allergy To Other Antibiotic Agent V14.2 Personal History Of Allergy To Sulfonamides V14.3 Personal History Of Allergy To Other Anti-infective Agent V14.4 Personal History Of Allergy To Anesthetic Agent V14.5 Personal History Of Allergy To Narcotic Agent V14.6 Personal History Of Allergy To Analgesic Agent V14.7 Personal History Of Allergy To Serum Or Vaccine V14.8 Personal History Of Allergy To Other Specified Medicinal Agents V14.9 Personal History Of Allergy To Unspecified Medicinal Agent V15.01 Personal History Of Allergy To Peanuts V15.02 Personal History Of Allergy To Milk Products V15.03 Personal History Of Allergy To Eggs V15.04 Personal History Of Allergy To Seafood V15.05 Personal History Of Allergy To Other Foods V15.06 Allergy To Insects And Arachnids V15.07 Personal History Of Allergy To Latex V15.08 Personal History Of Allergy To Radiographic Dye V15.09 Personal History Of Other Allergy Other Than To Medicinal Agents 08/13/15
Medicare Local Coverage Determination Policy - LA L36214 Assays for Vitamins and Metabolic Function Blood Folic Acid Serum CPT Code: 82746 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Folate (82746) can be tested up to four times per year for malabsorption syndromes (579.9) or deficiency disorders (266.2, 281.1 and 281.2). ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Blood Folic Acid Serum 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. 040.2 Whipple's Disease 261 Nutritional Marasmus 262 Other Severe Protein-Calorie Malnutrition 263.0 Malnutrition Of Moderate Degree 263.2 Arrested Development Following Protein-Calorie Malnutrition 263.8-263.9 Other Protein-Calorie Malnutrition - Unspecified Protein-Calorie Malnutrition 266.2 Other B-Complex Deficiencies 270.4 Disturbances Of Sulphur-Bearing Amino-Acid Metabolism 281.0-281.3 Pernicious Anemia - Other Specified Megaloblastic Anemias Not Elsewhere Classified 281.9 Unspecified Deficiency Anemia 287.5 Thrombocytopenia Unspecified 290.0 Senile Dementia Uncomplicated 303.91-303.92 Other And Unspecified Alcohol Dependence Continuous Drinking Behavior - Other And Unspecified Alcohol Dependence Episodic Drinking Behavior 331.0 Alzheimer's Disease 333.99 Other Extrapyramidal Diseases And Abnormal Movement Disorders 356.4 Idiopathic Progressive Polyneuropathy 356.9 Unspecified Idiopathic Peripheral Neuropathy 529.0 Glossitis 529.6 Glossodynia 536.0 Achlorhydria 555.0-555.2 Regional Enteritis Of Small Intestine - Regional Enteritis Of Small Intestine With Large Intestine 555.9 Regional Enteritis Of Unspecified Site 579.0-579.4 Celiac Disease - Pancreatic Steatorrhea 579.8-579.9 Other Specified Intestinal Malabsorption - Unspecified Intestinal Malabsorption 780.93 Memory Loss 780.99* Other General Symptoms *Note: Use code 780.99 to identify altered mental status 781.2 Abnormality Of Gait 781.3 Lack Of Coordination 782.0 Disturbance Of Skin Sensation V12.1 Personal History Of Nutritional Deficiency V45.11 Renal Dialysis Status V45.3 Postsurgical Intestinal Bypass Or Anastomosis Status V58.11 Encounter For Antineoplastic Chemotherapy V58.69 Long-Term (Current) Use Of Other Medications
L36214 Assays for Vitamins and Metabolic Function C-Reactive Protein HS CPT Codes: 86141 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Medicare will not cover more than two high-sensitivity C-reactive protein (86141) tests per year per beneficiary. This allows for baseline testing and six-month follow-up tests for statin therapeutic management. ICD-9-CM Codes that Support Medical Necessity The Vitamin Assays C Reactive Protein is determined to be medically necessary by Medicare only when they are 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. 272.0 Pure Hypercholesterolemia 414.01 Coronary atherosclerosis of native coronary artery
Medicare Local Coverage Determination Policy LA L32614 Assays for Vitamins and Metabolic Function Assay of Carnitine CPT Code: 82379 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Carnitine (82379) may be tested up to three times per year to account for baseline assay followed by evaluations at sixmonth increments (adapted from Levocarnitine NCD). ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Carnitine 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. 277.81-277.84 Primary Carnitine Deficiency - Other Secondary Carnitine Deficiency 285.21 Anemia In Chronic Kidney Disease 458.21 Hypotension Of Hemodialysis
L36214 Assays for Vitamins and Metabolic Function Cell Function Assay with Stimulation and Lymphocyte Transformation CPT Codes: 86352 and 86353 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. CD-9-CM Codes that Support Medical Necessity The Vitamin Assays Cell Function with Stimulation and Lymphocyte Transformation tests are determined to be medically necessary by Medicare only when they are 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. 279.10-279.13 Immunodeficiency With Predominant T-Cell Defect Unspecified - Nezelof's Syndrome 996.81-996.88 Complications Of Transplanted Kidney - Complications Of Transplanted Organ, Stem Cell V42.0 Kidney Replaced By Transplant V42.1 Heart Replaced By Transplant V42.6 Lung Replaced By Transplant V42.7 Liver Replaced By Transplant V42.81 Bone Marrow Replaced By Transplant V42.83 Pancreas Replaced By Transplant V42.84 Organ Or Tissue Replaced By Transplant Intestines
L36214 Assays for Vitamins and Metabolic Function Fibrinogen CPT Code: 85385 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Fibrinogen (85385) may be tested up to four times per year for low platelet diagnoses (287.30 287.33, 287.41, 287.49, 287.5). ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Fibrinogen 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. 286.3 Congenital Deficiency Of Other Clotting Factors 286.6-286.7 Defibrination Syndrome - Acquired Coagulation Factor Deficiency 287.30-287.33 Primary Thrombocytopenia,Unspecified - Congenital And Hereditary Thrombocytopenic Purpura 287.41 Posttransfusion Purpura 287.49 Other Secondary Thrombocytopenia 287.5 Thrombocytopenia Unspecified 790.92 Abnormal Coagulation Profile
L32614 Assays for Vitamins and Metabolic Function Assay of Homocystine CPT Code: 83090 LCD Description: LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay - Homocysteine 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. 040.2 Whipple's Disease 261 Nutritional Marasmus 262 Other Severe Protein-Calorie Malnutrition 263.0 Malnutrition Of Moderate Degree 263.2 Arrested Development Following Protein-Calorie Malnutrition 263.8-263.9 Other Protein-Calorie Malnutrition - Unspecified Protein-Calorie Malnutrition 266.2 Other B-Complex Deficiencies 270.4 Disturbances Of Sulphur-Bearing Amino-Acid Metabolism 281.0-281.3 Pernicious Anemia - Other Specified Megaloblastic Anemias Not Elsewhere Classified 281.9 Unspecified Deficiency Anemia 287.5 Thrombocytopenia Unspecified 290.0 Senile Dementia Uncomplicated 303.91-303.92 Other And Unspecified Alcohol Dependence Continuous Drinking Behavior - Other And Unspecified Alcohol Dependence Episodic Drinking Behavior 331.0 Alzheimer's Disease 333.99 Other Extrapyramidal Diseases And Abnormal Movement Disorders 356.4 Idiopathic Progressive Polyneuropathy 356.9 Unspecified Idiopathic Peripheral Neuropathy 529.0 Glossitis 529.6 Glossodynia 536.0 Achlorhydria 555.0-555.2 Regional Enteritis Of Small Intestine - Regional Enteritis Of Small Intestine With Large Intestine 555.9 Regional Enteritis Of Unspecified Site 579.0-579.4 Celiac Disease - Pancreatic Steatorrhea 579.8-579.9 Other Specified Intestinal Malabsorption - Unspecified Intestinal Malabsorption 780.93 Memory Loss 780.99* Other General Symptoms *Note: Use code 780.99 to identify altered mental status 781.2 Abnormality Of Gait 781.3 Lack Of Coordination 782.0 Disturbance Of Skin Sensation V12.1 Personal History Of Nutritional Deficiency V45.11 Renal Dialysis Status V45.3 Postsurgical Intestinal Bypass Or Anastomosis Status V58.11 Encounter For Antineoplastic Chemotherapy V58.69 Long-Term (Current) Use Of Other Medications 05/01/13
L36214 Assays for Vitamins and Metabolic Function Assay Lipoprotein PLA2 CPT Codes: 83698 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: The same frequency edit (two tests per year per beneficiary) will be applied to Lipoprotein-associated phospholipase A 2 (Lp- PLA 2 ) used in the management of patients with coronary artery disease. ICD-9-CM Codes that Support Medical Necessity The Vitamin Lipoprotein PLA2 test is determined to be medically necessary by Medicare only when they are 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. 250.00 Diabetes Mellitus Without Mention Of Complication, Type Ii Or Unspecified Type, Not Stated As Uncontrolled 250.02 Diabetes Mellitus Without Mention Of Complication, Type Ii Or Unspecified Type, Uncontrolled 272.0 Pure Hypercholesterolemia 272.1 Pure Hyperglyceridemia 272.2 Mixed Hyperlipidemia 272.3 Hyperchylomicronemia 272.4 Other And Unspecified Hyperlipidemia 414.01 Coronary Atherosclerosis Of Native Coronary Artery 414.4 Coronary Atherosclerosis Due To Calcified Coronary Lesion
L36214 Assays for Vitamins and Metabolic Function Assay of Vitamin B-6 CPT Code: 84207 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Vitamin B-6 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. 266.1 Vitamin B6 Deficiency 285.0 Sideroblastic Anemia 333.99 Other Extrapyramidal Diseases And Abnormal Movement Disorders 356.9 Unspecified Idiopathic Peripheral Neuropathy 529.0 Glossitis 3
L36214 Assays for Vitamins and Metabolic Function Vitamin B-12 CPT Code: 82607 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Vitamin B-12 (82607) can be tested up to four times per year for malabsorption syndromes (579.9) or deficiency disorders (266.2, 281.1 and 281.2). Vitamin B-12 (82607) can only be tested more frequently than four times per year for postsurgical malabsorption (579.3). ICD-9-CM Codes that Support Medical Necessity The Vitamin Assay Vitamin B-12 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. 040.2 Whipple's Disease 261 Nutritional Marasmus 262 Other Severe Protein-Calorie Malnutrition 263.0 Malnutrition Of Moderate Degree 263.2 Arrested Development Following Protein-Calorie Malnutrition 263.8-263.9 Other Protein-Calorie Malnutrition - Unspecified Protein-Calorie Malnutrition 266.2 Other B-Complex Deficiencies 270.4 Disturbances Of Sulphur-Bearing Amino-Acid Metabolism 281.0-281.3 Pernicious Anemia - Other Specified Megaloblastic Anemias Not Elsewhere Classified 281.9 Unspecified Deficiency Anemia 287.5 Thrombocytopenia Unspecified 290.0 Senile Dementia Uncomplicated 303.91-303.92 Other And Unspecified Alcohol Dependence Continuous Drinking Behavior - Other And Unspecified Alcohol Dependence Episodic Drinking Behavior 331.0 Alzheimer's Disease 333.99 Other Extrapyramidal Diseases And Abnormal Movement Disorders 356.4 Idiopathic Progressive Polyneuropathy 356.9 Unspecified Idiopathic Peripheral Neuropathy 529.0 Glossitis 529.6 Glossodynia 536.0 Achlorhydria 555.0-555.2 Regional Enteritis Of Small Intestine - Regional Enteritis Of Small Intestine With Large Intestine 555.9 Regional Enteritis Of Unspecified Site 579.0-579.4 Celiac Disease - Pancreatic Steatorrhea 579.8-579.9 Other Specified Intestinal Malabsorption - Unspecified Intestinal Malabsorption 780.93 Memory Loss 780.99* Other General Symptoms *Note: Use code 780.99 to identify altered mental status 781.2 Abnormality Of Gait 781.3 Lack Of Coordination 782.0 Disturbance Of Skin Sensation V12.1 Personal History Of Nutritional Deficiency V45.11 Renal Dialysis Status V45.3 Postsurgical Intestinal Bypass Or Anastomosis Status V58.11 Encounter For Antineoplastic Chemotherapy V58.69 Long-Term (Current) Use Of Other Medications
Medicare Local Coverage Determination Policy - LA L36214 Assays for Vitamins and Metabolic Function Vitamin D 1 25-dihydroxy (Includes Fractions if Performed) CPT Codes: 82652 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. ICD-9-CM Codes that Support Medical Necessity The Vitamin Assays Vitamin D, 25-hydroxy and Vitamin D1. 25-dihydroxy tests - are determined to be medically necessary by Medicare only when they are 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. 252.00-252.02 Hyperparathyroidism, Unspecified - Secondary Hyperparathyroidism, Non-Renal 252.08 Other Hyperparathyroidism 252.1 Hypoparathyroidism 268.0 Rickets Active 268.2 Osteomalacia Unspecified 268.9 Unspecified Vitamin D Deficiency 275.3 Disorders Of Phosphorus Metabolism 275.41-275.42 Hypocalcemia - Hypercalcemia 585.3-585.6 Chronic Kidney Disease, Stage III (Moderate) - End Stage Renal Disease 588.81 Secondary Hyperparathyroidism (Of Renal Origin) 733.00-733.03 Osteoporosis Unspecified - Disuse Osteoporosis 733.09 Other Osteoporosis 733.90 Disorder Of Bone And Cartilage Unspecified
L36214 Assays for Vitamins and Metabolic Function Vitamin D 25-hydroxy (Includes Fractions if Performed) CPT Codes: 82306 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: 25-OH Vitamin D-3 (82306) may be tested up to four times per year for Vitamin D deficiencies (268.0 268.9). ICD-9-CM Codes that Support Medical Necessity The Vitamin Assays Vitamin D, 25-hydroxy and Vitamin D1. 25-dihydroxy tests - are determined to be medically necessary by Medicare only when they are 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. 252.00-252.02 Hyperparathyroidism, Unspecified - Secondary Hyperparathyroidism, Non-Renal 252.08 Other Hyperparathyroidism 252.1 Hypoparathyroidism 268.0 Rickets Active 268.2 Osteomalacia Unspecified 268.9 Unspecified Vitamin D Deficiency 275.3 Disorders Of Phosphorus Metabolism 275.41-275.42 Hypocalcemia - Hypercalcemia 585.3-585.6 Chronic Kidney Disease, Stage III (Moderate) - End Stage Renal Disease 588.81 Secondary Hyperparathyroidism (Of Renal Origin) 733.00-733.03 Osteoporosis Unspecified - Disuse Osteoporosis 733.09 Other Osteoporosis 733.90 Disorder Of Bone And Cartilage Unspecified
L32614 Assays for Vitamins and Metabolic Function Non-Covered Services/Frequency Limitations CPT Codes: 82180, 84252, 84255, 84425, 84446, 84590, 84591, 84597, 84999 LCD Description: Vitamin or micronutrient testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors. Utilization Guidelines: Limited coverage is not being established, at this time, for CPT codes 82180, 84252, 84425, 84446, 84590 and 84597. Medicare will not cover more than one test per year, per beneficiary. Non Covered Codes 84255 Assays of selenium 84591 Assays of vitamin testing, not otherwise classified 84999 Functional Intracellular Analysis 84999 Total Antioxidant Function Frequency Limitations 82180 Assay of ascorbic acid 84252 Assay of vitamin b-2 84425 Assay of vitamin b-1 84446 Assay of vitamin e 84590 Assay of vitamin a 84597 Assay of vitamin k
Medicare Local Coverage Determination Policy LA L34796 Biomarkers for Oncology (Page 1 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 1 Medicare is establishing the following limited coverage for colorectal cancer molecular biomarkers (also including the small intestine): KRAS (12/13) 81275 KRAS codon 61 81403 KRAS codon 146 81479 NRAS 81404 BRAF 81210 PIK3CA 81479 MSI by PCR 81301 MLH1 promoter hypermethylation 81292, 81293, 81294 Group 1 Codes 152.0 MALIGNANT NEOPLASM OF DUODENUM 152.1 MALIGNANT NEOPLASM OF JEJUNUM 152.2 MALIGNANT NEOPLASM OF ILEUM 152.3 MALIGNANT NEOPLASM OF MECKEL'S DIVERTICULUM 152.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SMALL INTESTINE 152.9 MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE 153.0 MALIGNANT NEOPLASM OF HEPATIC FLEXURE 153.1 MALIGNANT NEOPLASM OF TRANSVERSE COLON 153.2 MALIGNANT NEOPLASM OF DESCENDING COLON 153.3 MALIGNANT NEOPLASM OF SIGMOID COLON 153.4 MALIGNANT NEOPLASM OF CECUM 153.5 MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS 153.6 MALIGNANT NEOPLASM OF ASCENDING COLON 153.7 MALIGNANT NEOPLASM OF SPLENIC FLEXURE 153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE 153.9 MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE 06/05/15
L34796 Biomarkers for Oncology (Page 2 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 2 Medicare is establishing the following limited coverage for non-small cell lung carcinoma (NSCLC) molecular biomarkers: EGFR 81235 KRAS (12/13) 81275 KRAS codon 61 81403 KRAS codon 146 81479 BRAF 81210 Group 2 Codes 162.0 MALIGNANT NEOPLASM OF TRACHEA 162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS 162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG 162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG 162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG 162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG 162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED 163.0 MALIGNANT NEOPLASM OF PARIETAL PLEURA 163.1 MALIGNANT NEOPLASM OF VISCERAL PLEURA 163.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PLEURA 163.9 MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED 06/05/15
L34796 Biomarkers for Oncology (Page 3 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 3 Medicare is establishing the following limited coverage for melanoma molecular biomarkers: BRAF 81210 KIT 81404 NRAS 81404 Group 3 Codes 172.0 MALIGNANT MELANOMA OF SKIN OF LIP 172.1 MALIGNANT MELANOMA OF SKIN OF EYELID INCLUDING CANTHUS 172.2 MALIGNANT MELANOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL 172.3 MALIGNANT MELANOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE 172.4 MALIGNANT MELANOMA OF SKIN OF SCALP AND NECK 172.5 MALIGNANT MELANOMA OF SKIN OF TRUNK EXCEPT SCROTUM 172.6 MALIGNANT MELANOMA OF SKIN OF UPPER LIMB INCLUDING SHOULDER 172.7 MALIGNANT MELANOMA OF SKIN OF LOWER LIMB INCLUDING HIP 172.8 MALIGNANT MELANOMA OF OTHER SPECIFIED SITES OF SKIN 172.9 MELANOMA OF SKIN SITE UNSPECIFIED 06/05/15
L34796 Biomarkers for Oncology (Page 4 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 4 Medicare is establishing the following limited coverage for brain molecular biomarkers: BRAF 81210 EGFR 81235 MGMT 81287 IDH1 81403 IDH2 81403 PIK3CA 81479 PTEN 81321, 81322, 81323, 81479 CIMP 81479 Group 4 Codes 191.0 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES 191.1 MALIGNANT NEOPLASM OF FRONTAL LOBE 191.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE 191.3 MALIGNANT NEOPLASM OF PARIETAL LOBE 191.4 MALIGNANT NEOPLASM OF OCCIPITAL LOBE 191.5 MALIGNANT NEOPLASM OF VENTRICLES 191.6 MALIGNANT NEOPLASM OF CEREBELLUM NOS 191.7 MALIGNANT NEOPLASM OF BRAIN STEM 191.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN 191.9 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE 06/05/15
L34796 Biomarkers for Oncology (Page 5 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 5 Medicare is establishing the following limited coverage for thyroid molecular biomarkers, for either documented, presumed or indeterminate malignancy: BRAF 81210 KRAS 81275, 81403, 81479 HRAS 81403 NRAS 81404 PIK3CA 81479 RET 81404 PAX8/PPARG 81401 Group 5 Codes 193 MALIGNANT NEOPLASM OF THYROID GLAND 226 BENIGN NEOPLASM OF THYROID GLANDS 237.4 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED ENDOCRINE GLANDS 241.0 NONTOXIC UNINODULAR GOITER 241.1 NONTOXIC MULTINODULAR GOITER 246.2 CYST OF THYROID 06/05/15
L34796 Biomarkers for Oncology (Page 6 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 6 Medicare is establishing the following limited coverage for uterus/ovary/fallopian tube/peritoneum molecular biomarkers: AKT1 81479 BRAF 81210 KRAS 81275, 81403, 81479 MLH1 promoter hypermethylation 81292, 81293, 81294 MSI by PCR 81301 PIK3CA 81479 PTEN 81321, 81322, 81323, 81479 TP53 81405 Group 6 Codes 158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM 158.9 MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED 182.0 MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS 182.1 MALIGNANT NEOPLASM OF ISTHMUS 182.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BODY OF UTERUS 183.0 MALIGNANT NEOPLASM OF OVARY 183.2 MALIGNANT NEOPLASM OF FALLOPIAN TUBE 183.3 MALIGNANT NEOPLASM OF BROAD LIGAMENT OF UTERUS 183.4 MALIGNANT NEOPLASM OF PARAMETRIUM 183.5 MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS 183.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA 183.9 MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE 06/05/15
L34796 Biomarkers for Oncology (Page 7 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 7 Medicare is establishing the following limited coverage for urinary tract molecular biomarkers: MSI by PCR 81301 MLH1 promoter hypermethylation 81292, 81293, 81294 Group 7 Codes 189.1 MALIGNANT NEOPLASM OF RENAL PELVIS 189.2 MALIGNANT NEOPLASM OF URETER 189.3 MALIGNANT NEOPLASM OF URETHRA 189.4 MALIGNANT NEOPLASM OF PARAURETHRAL GLANDS 189.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF URINARY ORGANS 189.9 MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED 06/05/15
L34796 Biomarkers for Oncology (Page 8 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 8 Medicare is establishing the following limited coverage for prostate cancer molecular biomarkers: PROGENSA PCA3 Assay 81313 Group 8 Codes 185 MALIGNANT NEOPLASM OF PROSTATE 600.00 HYPERTROPHY (BENIGN) OF PROSTATE WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT (LUTS) 600.01 HYPERTROPHY (BENIGN) OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS) 600.10 NODULAR PROSTATE WITHOUT URINARY OBSTRUCTION 600.11 NODULAR PROSTATE WITH URINARY OBSTRUCTION 600.20 BENIGN LOCALIZED HYPERPLASIA OF PROSTATE WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS) 600.21 BENIGN LOCALIZED HYPERPLASIA OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS LUTS) 600.3 CYST OF PROSTATE 600.90 HYPERPLASIA OF PROSTATE, UNSPECIFIED, WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY SYMPTOMS LUTS) 600.91 HYPERPLASIA OF PROSTATE, UNSPECIFIED, WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY SYMPTOMS (LUTS) Group 9 Medicare is establishing the following limited coverage for gastrointestinal stromal tumor molecular biomarkers: KIT 81404 PDGFRA 81404 Group 9 Codes 238.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF CONNECTIVE AND OTHER SOFT TISSUE 06/05/15
L34796 Biomarkers for Oncology (Page 9 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 10 Medicare is establishing the following limited coverage for acute lymphoid leukemia (ALL) molecular biomarkers: BCR/ABL1 81206, 81207, 81208 ABL1 (kinase domain) 81403 IGH 81261 TCRB 81340 TCRG 81342 TP53 81405 MLL/AF4 81479 E2A/PBX1 81401 ETV6/RUNX1 81401 Group 10 Codes 204.00 ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 204.01 LYMPHOID LEUKEMIA ACUTE IN REMISSION 204.02 ACUTE LYMPHOID LEUKEMIA, IN RELAPSE 06/05/15
L34796 Biomarkers for Oncology (Page 10 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 11 Medicare is establishing the following limited coverage for acute myeloid leukemia (AML, and including acute promyelocytic leukemia) molecular biomarkers: PML/RARA 81315 IDH1 81403 RUNX1/RUNX1T1 81401 IDH2 81403 CBFB/MYH11 81401 DNMT3A 81403 FLT3 ITD 81245 JAK2 (p.v617f) 81270 FLT3 D836 81479 JAK2 (exon 12) 81403 NPM1 81310 MPL 81402 KRAS 81275, 81403, 81479 DEK/CAN 81479 NRAS 81404 ASXL1 81479 KIT 81402 EZH2 81479 CEBPA 81403 TET2 81479 Group 11 Codes 205.00 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 205.01 MYELOID LEUKEMIA ACUTE IN REMISSION 205.02 ACUTE MYELOID LEUKEMIA, IN RELAPSE 06/05/15
L34796 Biomarkers for Oncology (Page 11 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 12 Medicare is establishing the following limited coverage for hairy cell leukemia molecular biomarkers: IGH somatic hypermutation 81263 IGH 81261 Group 12 Codes 202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE 202.41 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK 202.42 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES 202.43 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES 202.44 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM 202.45 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 202.46 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES 202.47 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN 202.48 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES Group 13 Medicare is establishing the following limited coverage for aplastic anemia molecular biomarkers: TCRB 81340 TCRG 81342 Group 13 Codes 284.01 CONSTITUTIONAL RED BLOOD CELL APLASIA 284.09 OTHER CONSTITUTIONAL APLASTIC ANEMIA 284.81 RED CELL APLASIA (ACQUIRED) (ADULT) (WITH THYMOMA) 284.89 OTHER SPECIFIED APLASTIC ANEMIAS 284.9 APLASTIC ANEMIA UNSPECIFIED 06/05/15
L34796 Biomarkers for Oncology (Page 12 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 14 Medicare is establishing the following limited coverage for Burkitt s lymphoma molecular biomarkers: IGH 81261 TP53 81405 Group 14 Codes 200.20 BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE 200.21 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK 200.22 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES 200.23 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES 200.24 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB 200.25 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 200.26 BURKITT'S TUMOR OR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES 200.27 BURKITT'S TUMOR OR LYMPHOMA INVOLVING SPLEEN 200.28 BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 06/05/15
L34796 Biomarkers for Oncology (Page 13 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 15 Medicare is establishing the following limited coverage for myeloproliferative diseases (MPD - essential thrombocytosis [ET], myelofibrosis & polycythemia vera [PV]) molecular biomarkers: BCR/ABL1 81206, 81207, 81208 JAK2 (p.v617f) 81270 JAK2 (exon 12) 81403 MPL 81402 CALR 81479 CSF3R 81479 ASXL1 81479 TET2 81479 EZH2 81479 Group 15 Codes 238.4 POLYCYTHEMIA VERA 238.71 ESSENTIAL THROMBOCYTHEMIA 238.76 MYELOFIBROSIS WITH MYELOID METAPLASIA 289.83 MYELOFIBROSIS 06/05/15
L34796 Biomarkers for Oncology (Page 14 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 16 Medicare is establishing the following limited coverage for chronic myeloid leukemia (CML) and chronic myelomonocytic leukemia (CMML) molecularbiomarkers: KRAS 81275, 81403 NRAS 81404 BCR/ABL1 81206, 81207, 81208 ABL1 (kinase domain) 81403 FLT3 ITD 81245 FLT3 D836 81479 KIT 81402 JAK2 (p.v617f) 81270 JAK2 (exon 12) 81403 Group 16 Codes 205.10 CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 205.11 MYELOID LEUKEMIA CHRONIC IN REMISSION 205.12 CHRONIC MYELOID LEUKEMIA, IN RELAPSE 06/05/15
L34796 Biomarkers for Oncology (Page 15 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 17 Medicare is establishing the following limited coverage for chronic lymphoid leukemia (CLL) molecular biomarkers: IGH 81261 IGH somatic hypermutation 81263 ATM 81479 TP53 81405 Group 17 Codes 204.10 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 204.11 LYMPHOID LEUKEMIA CHRONIC IN REMISSION 204.12 CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE Group 18 Medicare is establishing the following limited coverage for follicular lymphoma molecular biomarkers: IGH/BCL2 81479 Group 18 Codes 202.00 NODULAR LYMPHOMA UNSPECIFIED SITE 202.01 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK 202.02 NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES 202.03 NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES 202.04 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB 202.05 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 202.06 NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES 202.07 NODULAR LYMPHOMA INVOLVING SPLEEN 202.08 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 06/05/15
L34796 Biomarkers for Oncology (Page 16 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 19 Medicare is establishing the following limited coverage for Hypereosinophilia Syndrome (HES) molecular biomarkers: KIT (including p.d816v) 81402 FIP1L1/PDGFRA Fusion 81401 Group 19 Codes 288.3 EOSINOPHILIA Group 20 Medicare is establishing the following limited coverage for mantle cell lymphoma molecular biomarkers: CCND1/IGH 81401 Group 19 Codes 200.40 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES 200.41 MANTLE CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK 200.42 MANTLE CELL LYMPHOMA, INTRATHORACIC LYMPH NODES 200.43 MANTLE CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES 200.44 MANTLE CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB 200.45 MANTLE CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 200.46 MANTLE CELL LYMPHOMA, INTRAPELVIC LYMPH NODES 200.47 MANTLE CELL LYMPHOMA, SPLEEN 200.48 MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 06/05/15
L34796 Biomarkers for Oncology (Page 17 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 21 Medicare is establishing the following limited coverage for mastocytosis molecular biomarkers: KIT (including p.d816v) 81402 FIP1L1/PDGFRA Fusion 81401 TCRG 81342 Group 21 Codes 202.60 MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE 202.61 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK 202.62 MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES 202.63 MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES 202.64 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB 202.65 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 202.66 MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES 202.67 MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN 202.68 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES 06/05/15
L34796 Biomarkers for Oncology (Page 18 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 22 Medicare is establishing the following limited coverage for T-cell prolymphocytic leukemia molecular biomarkers: TCRB 81340 TCRG 81342 Group 22 Codes 208.90 UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 208.91 UNSPECIFIED LEUKEMIA IN REMISSION 208.92 UNSPECIFIED LEUKEMIA, IN RELAPSE 06/05/15
L34796 Biomarkers for Oncology (Page 19 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 23 Medicare is establishing the following limited coverage for myelodysplastic syndrome (MDS) molecular biomarkers: FLT3 ITD 81245 IDH2 81403 FLT3 D836 81479 DNMT3A 81403 NPM1 81310 JAK2 (p.v617f) 81270 KRAS 81275, 81403, 81479 JAK2 (exon 12) 81403 NRAS 81404 MPL 81402 KIT 81402 ASXL1 81479 CEBPA 81403 EZH2 81479 IDH1 81403 TET2 81479 Group 23 Codes 238.72 LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.73 HIGH GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.74 MYELODYSPLASTIC SYNDROME WITH 5Q DELETION 238.75 MYELODYSPLASTIC SYNDROME, UNSPECIFIED 06/05/15
L34796 Biomarkers for Oncology (Page 20 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 24 Medicare is establishing the following limited coverage for cytogenomic microarray analysis (81406), or alternatively a single nucleotide polymorphism (SNP) array for the same testing, whose resultant mutation identifications are used in the diagnosis/prognosis of various hematological malignancies. Group 24 Codes 203.00 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 203.01 MULTIPLE MYELOMA IN REMISSION 203.02 MULTIPLE MYELOMA, IN RELAPSE 204.10 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 205.00 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 206.00 ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 206.01 MONOCYTIC LEUKEMIA ACUTE IN REMISSION 206.02 ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE 206.10 CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 207.00 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 238.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS 238.72 LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.73 HIGH GRADE MYELODYSPLASTIC SYNDROME LESIONS 238.74 MYELODYSPLASTIC SYNDROME WITH 5Q DELETION 238.75 MYELODYSPLASTIC SYNDROME, UNSPECIFIED 273.0 POLYCLONAL HYPERGAMMAGLOBULINEMIA 273.1 MONOCLONAL PARAPROTEINEMIA 06/05/15
L34796 Biomarkers for Oncology (Page 21 of 21) CPT Codes: 81206, 81207, 81208, 81210, 81235, 81245, 81246, 81261, 81263, 81270, 81275, 81287, 81292, 81293, 81294, 81301, 81310, 81313, 81315, 81321, 81322, 81323, 81340, 81342, 81350, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81435, 81436, 81479 LCD Description: This current document focuses upon selected testing in oncology, with some emphasis upon applying the revised 2015 CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Group 25 Medicare is establishing the following limited coverage for Myeloma gene expression profile (MyPRS) (81479): Group 25 Codes 203.00* MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION 203.02* MULTIPLE MYELOMA, IN RELAPSE Note: 203.00 should be reported after initial diagnosis has been made and 203.02 should be reported if there has been a relapse with a change in treatment planned. 06/05/15
L33638 Biomarkers Overview (Page 1 of 6) CPT Codes: 81161, 81200, 81201, 81202, 81203, 81205, 81209, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81240, 81241, 81242, 81243, 81244, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81260, 81265, 81266, 81267, 81268, 81280, 81281, 81282, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81330, 81331, 81332, 81355, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383 LCD Description: This current LCD focuses upon selected testing in oncology, with some emphasis upon applying the revised 2013 (and 2014) CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Covered Codes 81201 Apc gene full sequence 81202 Apc gene known fam variants 81203 Apc gene dup/delet variants 81211 Brca1&2 seq & com dup/del 81212 Brca1&2 185&5385&6174 var 81213 Brca1&2 uncom dup/del var 81214 Brca1 full seq & com dup/del 81215 Brca1 gene known fam variant 81216 Brca2 gene full sequence 81217 Brca2 gene known fam variant 81240 F2 gene 81241 F5 gene
L33638 Biomarkers Overview (Page 2 of 6 ) CPT Codes: 81161, 81200, 81201, 81202, 81203, 81205, 81209, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81240, 81241, 81242, 81243, 81244, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81260, 81265, 81266, 81267, 81268, 81280, 81281, 81282, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81330, 81331, 81332, 81355, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383 LCD Description: This current LCD focuses upon selected testing in oncology, with some emphasis upon applying the revised 2013 (and 2014) CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Covered Per LCD 34796 Biomarkers for Oncology 81292 Mlh 1 gene full seq 81293 Mlh 1 gene known variants 81294 Mlh 1 gene dup/delete variant 81301 Microsatellite instability 81321 Pten gene full sequence 81322 Pten gene known fam variant 81323 Pten gene dup/delet variant
L33638 Biomarkers Overview (Page 3 of 6 ) CPT Codes: 81161, 81200, 81201, 81202, 81203, 81205, 81209, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81240, 81241, 81242, 81243, 81244, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81260, 81265, 81266, 81267, 81268, 81280, 81281, 81282, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81330, 81331, 81332, 81355, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383 LCD Description: This current LCD focuses upon selected testing in oncology, with some emphasis upon applying the revised 2013 (and 2014) CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Covered If Age Less Than 40 81250 G6pc gene 81251 Gba gene 81252 Gjb2 gene full sequence 81253 Gjb2 gene known fam variants 81254 Gjb6 gene com variants 81255 Hexa gene 81290 Mcoln1 gene
L33638 Biomarkers Overview (Page 4 of 6) CPT Codes: 81161, 81200, 81201, 81202, 81203, 81205, 81209, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81240, 81241, 81242, 81243, 81244, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81260, 81265, 81266, 81267, 81268, 81280, 81281, 81282, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81330, 81331, 81332, 81355, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383 LCD Description: This current LCD focuses upon selected testing in oncology, with some emphasis upon applying the revised 2013 (and 2014) CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Covered If Age Less Than 50 81324 Pmp22 gene dup/delet 81325 Pmp22 gene full sequence 81252 Pmp22 gene known fam variant
L33638 Biomarkers Overview (Page 5 of 6) CPT Codes: 81161, 81200, 81201, 81202, 81203, 81205, 81209, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81240, 81241, 81242, 81243, 81244, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81260, 81265, 81266, 81267, 81268, 81280, 81281, 81282, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81330, 81331, 81332, 81355, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383 LCD Description: This current LCD focuses upon selected testing in oncology, with some emphasis upon applying the revised 2013 (and 2014) CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Covered If Age Less Than 65 81242 Fancc gene 81256 Hfe gene 81257 Hba1/hba2 gene 81295 Msh2 gene full seq 81296 Msh2 gene known variants 81297 Msh2 gene dup/delete variant 81298 Msh6 gene full seq 81299 Msh6 gene known variants 81300 Msh6 gene dup/delete variant 81317 Pms2 gene full seq analysis 81318 Pms2 known familial variants 81319 Pms2 gene dup/delet variants 81332 Serpina1 gene
L33638 Biomarkers Overview (Page 6 of 6) CPT Codes: 81161, 81200, 81201, 81202, 81203, 81205, 81209, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81240, 81241, 81242, 81243, 81244, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81260, 81265, 81266, 81267, 81268, 81280, 81281, 81282, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81330, 81331, 81332, 81355, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383 LCD Description: This current LCD focuses upon selected testing in oncology, with some emphasis upon applying the revised 2013 (and 2014) CPT molecular coding format. The official NIH definition of a biomarker is: "a characteristic that is objectively measured and evaluated as an indicator of normal biologic processes pathogenic processes, or pharmacologic response to a therapeutic intervention. Non Covered Codes 81161 Dmd dup/delet analysis 81200 Aspa gene 81205 Bckdhb gene 81209 Blm gene 81220 Cftr gene com variants 81221 Cftr gene known fam variants 81222 Cftr gene dup/delet variants 81223 Cftr gene full sequence 81224 Cftr gene intron poly t 81243 Fmr1 gene detection Non Covered Codes 81244 Fmr1 gene characterization 81260 Ikbkap gene 81280 Long qt synd gene full sequence 81281 Long qt synd known fam var 81282 Long qt syn gene dup/dlt var 81302 Mecp2 gene full seq 81303 Mecp2 gene known variant 81304 Mecp2 gene dup/delet variant 81330 Smpd1 gene common variants 81331 Snrpn/ube3a gene
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 1 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE 079.51-079.53 HUMAN T-CELL LYMPHOTROPHIC VIRUS TYPE I [HTLV-I] - HUMAN IMMUNODEFICIENCY VIRUS TYPE 2 [HIV-2] 099.3 REITER'S DISEASE 150.0-150.5 MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS - MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS 150.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS 150.9 MALIGNANT NEOPLASM OF ESOPHAGUS UNSPEC SITE 151.0-151.6 MALIGNANT NEOPLASM OF CARDIA - MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED 151.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH 152.0 MALIGNANT NEOPLASM OF DUODENUM 152.1 MALIGNANT NEOPLASM OF JEJUNUM 152.2 MALIGNANT NEOPLASM OF ILEUM 152.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SMALL INTESTINE 152.9 MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE 153.0-153.9 MALIGNANT NEOPLASM OF HEPATIC FLEXURE - MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE 154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION 154.1 MALIGNANT NEOPLASM OF RECTUM 154.2 MALIGNANT NEOPLASM OF ANAL CANAL 154.3 MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE 154.8 MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS 151.9 MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 2 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY 155.2 MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY 156.0 MALIGNANT NEOPLASM OF GALLBLADDER 156.1 MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS 156.2 MALIGNANT NEOPLASM OF AMPULLA OF VATER 157.0 MALIGNANT NEOPLASM OF HEAD OF PANCREAS 157.1 MALIGNANT NEOPLASM OF BODY OF PANCREAS 157.2 MALIGNANT NEOPLASM OF TAIL OF PANCREAS 157.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS 157.9 MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED 158.0 MALIGNANT NEOPLASM OF RETROPERITONEUM 158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM 158.9 MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED 159.0 MALIGNANT NEOPLASM OF INTESTINAL TRACT PART UNSPECIFIED 159.1 MALIGNANT NEOPLASM OF SPLEEN NOT ELSEWHERE CLASSIFIED 159.8 MALIGNANT NEOPLASM OF OTHER SITES OF DIGESTIVE SYSTEM AND INTRA-ABDOMINAL ORGANS 159.9 MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE DIGESTIVE ORGANS AND PERITONEUM 160.0 MALIGNANT NEOPLASM OF NASAL CAVITIES 160.1 MALIGNANT NEOPLASM OF AUDITORY TUBE MIDDLE EAR AND MASTOID AIR CELLS 160.2 MALIGNANT NEOPLASM OF MAXILLARY SINUS 160.3 MALIGNANT NEOPLASM OF ETHMOIDAL SINUS 160.4 MALIGNANT NEOPLASM OF FRONTAL SINUS 160.5 MALIGNANT NEOPLASM OF SPHENOIDAL SINUS 160.8 MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 3 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 160.9 MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED 161.0 MALIGNANT NEOPLASM OF GLOTTIS 161.1 MALIGNANT NEOPLASM OF SUPRAGLOTTIS 161.2 MALIGNANT NEOPLASM OF SUBGLOTTIS 161.3 MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES 161.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX 161.9 MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED 162.0 MALIGNANT NEOPLASM OF TRACHEA 162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS 162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG 162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG 162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG 162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG 162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED 163.0 MALIGNANT NEOPLASM OF PARIETAL PLEURA 163.1 MALIGNANT NEOPLASM OF VISCERAL PLEURA 163.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PLEURA 163.9 MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED 164.0 MALIGNANT NEOPLASM OF THYMUS 164.2 MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM 164.3 MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM 164.8 MALIGNANT NEOPLASM OF OTHER PARTS OF MEDIASTINUM 164.9 MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSPECIFIED 165.0 MALIGNANT NEOPLASM OF UPPER RESPIRATORY TRACT PART UNSPECIFIED
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 4 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 165.8 MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE RESPIRATORY SYSTEM AND INTRATHORACIC ORGANS 165.9 MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE RESPIRATORY SYSTEM 170.0 MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE EXCEPT MANDIBLE 170.2 MALIGNANT NEOPLASM OF VERTEBRAL COLUMN EXCLUDING SACRUM AND COCCYX 170.3 MALIGNANT NEOPLASM OF RIBS STERNUM AND CLAVICLE 170.4 MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES OF UPPER LIMB 170.5 MALIGNANT NEOPLASM OF SHORT BONES OF UPPER LIMB 170.6 MALIGNANT NEOPLASM OF PELVIC BONES SACRUM AND 170.7 MALIGNANT NEOPLASM OF LONG BONES OF LOWER LIMB 170.8 MALIGNANT NEOPLASM OF SHORT BONES OF LOWER LIMB 170.9 MALIGNANT NEOPLASM OF BONE AND ARTICULAR CARTILAGE SITE UNSPECIFIED 171.0 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK 171.2 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER 171.3 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP 171.4 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF THORAX 171.5 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER COCCYX SOFT TISSUE OF ABDOMEN
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 5 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 171.6 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF PELVIS 171.7 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF TRUNK UNSPECIFIED 171.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CONNECTIVE AND OTHER SOFT TISSUE 171.9 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED 173.00 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP 173.01 BASAL CELL CARCINOMA OF SKIN OF LIP 173.02 SQUAMOUS CELL CARCINOMA OF SKIN OF LIP 173.09 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP 173.10 UNSPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS 173.11 BASAL CELL CARCINOMA OF EYELID, INCLUDING CANTHUS 173.12 SQUAMOUS CELL CARCINOMA OF EYELID, INCLUDING CANTHUS 173.19 OTHER SPECIFIED MALIGNANT NEOPLASM OF EYELID, INCLUDING CANTHUS 173.20 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL 173.21 BASAL CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL 173.22 SQUAMOUS CELL CARCINOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL 173.29 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL 173.30 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 6 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 173.31 BASAL CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE 173.32 SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE 173.39 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE 173.40 UNSPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK 173.41 BASAL CELL CARCINOMA OF SCALP AND SKIN OF NECK 173.42 SQUAMOUS CELL CARCINOMA OF SCALP AND SKIN OF NECK 173.49 OTHER SPECIFIED MALIGNANT NEOPLASM OF SCALP AND SKIN OF NECK 173.50 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM 173.51 BASAL CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM 173.52 SQUAMOUS CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT SCROTUM 173.59 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF TRUNK, EXCEPT SCROTUM 173.60 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER 173.61 BASAL CELL CARCINOMA OF SKIN OF UPPER LIMB, I NCLUDING SHOULDER 173.62 SQUAMOUS CELL CARCINOMA OF SKIN OF UPPER LIMB, INCLUDING SHOULDER 173.69 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF UPPER LIMB, INCLUDING SHOULDER 173.70 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 7 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 173.71 BASAL CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP 173.72 SQUAMOUS CELL CARCINOMA OF SKIN OF LOWER LIMB, INCLUDING HIP 173.79 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF LOWER LIMB, INCLUDING HIP 173.80 UNSPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN 173.81 BASAL CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN 173.82 SQUAMOUS CELL CARCINOMA OF OTHER SPECIFIED SITES OF SKIN 173.89 OTHER SPECIFIED MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SKIN 173.90 UNSPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE 173.91 BASAL CELL CARCINOMA OF SKIN, SITE UNSPECIFIED 173.92 SQUAMOUS CELL CARCINOMA OF SKIN, SITE UNSPECIFIED 173.99 OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE UNSPECIFIED 174.0-174.6 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST - MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST 174.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST 174.9 MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE 175.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST 175.9 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED UNSPECIFIED SITES OF MALE BREAST
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 8 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 176.0 KAPOSI'S SARCOMA SKIN 176.1 KAPOSI'S SARCOMA SOFT TISSUE 176.2 KAPOSI'S SARCOMA PALATE 176.3 KAPOSI'S SARCOMA GASTROINTESTINAL SITES 176.4 KAPOSI'S SARCOMA LUNG 176.5 KAPOSI'S SARCOMA LYMPH NODES 176.8 KAPOSI'S SARCOMA OTHER SPECIFIED SITES 176.9 KAPOSI'S SARCOMA UNSPECIFIED SITE 179 MALIGNANT NEOPLASM OF UTERUS-PART UNS 180.0 MALIGNANT NEOPLASM OF ENDOCERVIX 180.1 MALIGNANT NEOPLASM OF EXOCERVIX 180.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CERVIX 180.9 MALIGNANT NEOPLASM OF CERVIX UTERI UNSPECIFIED SITE 182.0 MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS 182.1 MALIGNANT NEOPLASM OF ISTHMUS 182.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BODY OF UTERUS 183.0 MALIGNANT NEOPLASM OF OVARY 183.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA 184.0 MALIGNANT NEOPLASM OF VAGINA 184.1 MALIGNANT NEOPLASM OF LABIA MAJORA 184.2 MALIGNANT NEOPLASM OF LABIA MINORA 184.3 MALIGNANT NEOPLASM OF CLITORIS 184.4 MALIGNANT NEOPLASM OF VULVA UNSPECIFIED SITE 184.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE GENITAL ORGANS 181 MALIGNANT NEOPLASM OF PLACENTA
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 9 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 184.9 MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED 185 MALIGNANT NEOPLASM OF PROSTATE 186.0 MALIGNANT NEOPLASM OF UNDESCENDED TESTIS 186.9 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED TESTIS 187.1 MALIGNANT NEOPLASM OF PREPUCE 187.2 MALIGNANT NEOPLASM OF GLANS PENIS 187.3 MALIGNANT NEOPLASM OF BODY OF PENIS 187.4 MALIGNANT NEOPLASM OF PENIS PART UNSPECIFIED 187.5 MALIGNANT NEOPLASM OF EPIDIDYMIS 187.6 MALIGNANT NEOPLASM OF SPERMATIC CORD 187.7 MALIGNANT NEOPLASM OF SCROTUM 187.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF MALE GENITAL ORGANS 187.9 MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE UNSPECIFIED 188.0-188.9 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER - MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED 189.0 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS 189.1 MALIGNANT NEOPLASM OF RENAL PELVIS 189.2 MALIGNANT NEOPLASM OF URETER 189.3 MALIGNANT NEOPLASM OF URETHRA 189.4 MALIGNANT NEOPLASM OF PARAURETHRAL GLANDS 189.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF URINARY ORGANS 189.9 MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 10 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 190.0-190.9 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID - MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED 191.0-191.9 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE 192.0 MALIGNANT NEOPLASM OF CRANIAL NERVES 192.1 MALIGNANT NEOPLASM OF CEREBRAL MENINGES 192.2 MALIGNANT NEOPLASM OF SPINAL CORD 192.3 MALIGNANT NEOPLASM OF SPINAL MENINGES 192.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NERVOUS SYSTEM 192.9 MALIGNANT NEOPLASM OF NERVOUS SYSTEM PART UNSPECIFIED 193 MALIGNANT NEOPLASM OF THYROID GLAND 194.0 MALIGNANT NEOPLASM OF ADRENAL GLAND 194.1 MALIGNANT NEOPLASM OF PARATHYROID GLAND 194.3 MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT 194.4 MALIGNANT NEOPLASM OF PINEAL GLAND 194.5 MALIGNANT NEOPLASM OF CAROTID BODY 194.6 MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA 194.8 MALIGNANT NEOPLASM OF OTHER ENDOCRINE GLANDS AND RELATED STRUCTURES 194.9 MALIGNANT NEOPLASM OF ENDOCRINE GLAND SITE UNSPECIFIED 195.0-195.5 MALIGNANT NEOPLASM OF HEAD FACE AND NECK - MALIGNANT NEOPLASM OF LOWER LIMB 195.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES 196.0 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 11 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 196.1 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRATHORACIC LYMPH NODES 196.2 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRA-ABDOMINAL LYMPH NODES 196.3 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF AXILLA AND UPPER LIMB 196.5 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF INGUINAL REGION AND LOWER LIMB 196.6 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF INTRAPELVIC LYMPH NODES 196.8 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF MULTIPLE SITES 196.9 SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES SITE UNSPECIFIED 197.0 SECONDARY MALIGNANT NEOPLASM OF LUNG 197.1 SECONDARY MALIGNANT NEOPLASM OF MEDIASTINUM 197.2 SECONDARY MALIGNANT NEOPLASM OF PLEURA 197.3 SECONDARY MALIGNANT NEOPLASM OF OTHER RESPIRATORY ORGANS 197.4 SECONDARY MALIGNANT NEOPLASM OF SMALL INTESTINE INCLUDING DUODENUM 197.5 SECONDARY MALIGNANT NEOPLASM OF LARGE INTESTINE AND RECTUM 197.6 SECONDARY MALIGNANT NEOPLASM OF RETROPERITONEUM AND PERITONEUM 198.0-198.7 SECONDARY MALIGNANT NEOPLASM OF KIDNEY - SECONDARY MALIGNANT NEOPLASM OF ADRENAL GLAND 198.81 SECONDARY MALIGNANT NEOPLASM OF BREAST 198.82 SECONDARY MALIGNANT NEOPLASM OF GENITAL ORGANS
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 12 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 198.89 SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES 199.0 DISSEMINATED MALIGNANT NEOPLASM 199.1 OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE 200.00-200.08 RETICULOSARCOMA UNSPECIFIED SITE - RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 200.10-200.18 LYMPHOSARCOMA UNSPECIFIED SITE - LYMPHOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 200.20-200.28 BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE - BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 200.30-200.38 MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MARGINAL 200.40-200.48 MANTLE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - MANTLE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 200.50-200.58 PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 200.60-200.68 ANAPLASTIC LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - ANAPLASTIC LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 200.70-200.78 LARGE CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - LARGE CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 13 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 200.80-200.88 OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA UNSPECIFIED SITE - OTHER NAMED VARIANTS OF LYMPHOSARCOMA AND RETICULOSARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 201.00-201.08 HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE - HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 201.10-201.18 HODGKIN'S GRANULOMA UNSPECIFIED SITE - HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 201.20-201.28 HODGKIN'S SARCOMA UNSPECIFIED SITE - HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 201.40-201.48 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE - HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES 201.50-201.58 HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE - HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES 201.60-201.68 HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE - HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES 201.70-201.78 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE - HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 14 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 201.90-201.98 HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE - HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES 202.00-202.08 NODULAR LYMPHOMA UNSPECIFIED SITE - NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES 202.10-202.18 MYCOSIS FUNGOIDES UNSPECIFIED SITE - MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES 202.20-202.28 SEZARY'S DISEASE UNSPECIFIED SITE - SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES 202.30-202.38 MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE - MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES 202.40-202.48 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE - LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES 202.50-202.58 LETTERER-SIWE DISEASE UNSPECIFIED SITE - LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES 202.60-202.68 MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE - MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES 202.70-202.78 PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES - PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES 202.80-202.88 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE - OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 15 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 202.90-202.98 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 203.00-203.02 MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MULTIPLE MYELOMA, IN RELAPSE 203.10-203.12 PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - PLASMA CELL LEUKEMIA, IN RELAPSE 203.80-203.82 OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE 204.00-204.02 ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE LYMPHOID LEUKEMIA, IN RELAPSE 204.10-204.12 CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE 204.20-204.22 SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE 204.80-204.82 OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER LYMPHOID LEUKEMIA, IN RELAPSE 204.90-204.92 UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 16 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 205.00-205.02 ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MYELOID LEUKEMIA, IN RELAPSE 205.10-205.12 CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC MYELOID LEUKEMIA, IN RELAPSE 205.20-205.22 SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE MYELOID LEUKEMIA, IN RELAPSE 205.30-205.32 MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MYELOID SARCOMA, IN RELAPSE 205.80-205.82 OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER MYELOID LEUKEMIA, IN RELAPSE 205.90-205.92 UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE 206.00-206.02 ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE 206.10-206.12 CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE 206.20-206.22 SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE 206.80-206.82 OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER MONOCYTIC LEUKEMIA, IN RELAPSE
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 17 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 206.90-206.92 UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE 207.00-207.02 ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE 207.10-207.12 CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC ERYTHREMIA, IN RELAPSE 207.20-207.22 MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - MEGAKARYOCYTIC LEUKEMIA, IN RELAPSE 207.80-207.82 OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER SPECIFIED LEUKEMIA, IN RELAPSE 208.00-208.02 ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE 208.10-208.12 CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE 208.20-208.22 SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE 208.80-208.82 OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 18 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 208.90-208.92 UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION - UNSPECIFIED LEUKEMIA, IN RELAPSE 227.0 BENIGN NEOPLASM OF ADRENAL GLAND 233.0 CARCINOMA IN SITU OF BREAST 235.0-235.9 NEOPLASM OF UNCERTAIN BEHAVIOR OF MAJOR SALIVARY GLANDS - NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPEC RESPIRATORY ORGANS 236.0 NEOPLASM OF UNCERTAIN BEHAVIOR OF UTERUS 236.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF OVARY 236.3 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED FEMALE GENITAL ORGANS 236.4 NEOPLASM OF UNCERTAIN BEHAVIOR OF TESTIS 236.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF PROSTATE 236.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED MALE GENITAL ORGANS 236.7 NEOPLASM OF UNCERTAIN BEHAVIOR OF BLADDER 238.1 NEOPLASM OF UNCERTAIN BEHAVIOR OF CONNECTIVE AND OTHER SOFT TISSUE 238.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF SKIN 238.3 NEOPLASM OF UNCERTAIN BEHAVIOR OF BREAST 238.71-238.77 ESSENTIAL THROMBOCYTHEMIA - POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD) 238.79 OTHER LYMPHATIC AND HEMATOPOIETIC TISSUES 238.8 NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER SPECIFIED SITES 259.2 CARCINOID SYNDROME 273.1-273.3 MONOCLONAL PARAPROTEINEMIA - MACROGLOBULINEMIA 273.8-273.9 OTHER DISORDERS OF PLASMA PROTEIN METABOLISM - UNSPECIFIED DISORDER OF PLASMA PROTEIN METABOLISM
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 19 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 279.00-279.06 HYPOGAMMAGLOBULINEMIA UNSPECIFIED - COMMON VARIABLE IMMUNODEFICIENCY 279.09 OTHER DEFICIENCY OF HUMORAL IMMUNITY 279.10-279.13 IMMUNODEFICIENCY WITH PREDOMINANT T-CELL DEFECT UNSPECIFIED - NEZELOF'S SYNDROME 279.19 OTHER DEFICIENCY OF CELL-MEDIATED IMMUNITY 279.2 COMBINED IMMUNITY DEFICIENCY 279.3 UNSPECIFIED IMMUNITY DEFICIENCY 279.41 AUTOIMMUNE LYMPHOPROLIFERATIVE SYNDROME 279.49 AUTOIMMUNE DISEASE, NOT ELSEWHERE CLASSIFIED 279.50-279.53 GRAFT-VERSUS-HOST DISEASE, UNSPECIFIED - ACUTE ON CHRONIC GRAFT-VERSUS-HOST DISEASE 279.8-279.9 OTHER SPECIFIED DISORDERS INVOLVING THE IMMUNE MECHANISM - UNSPECIFIED DISORDER OF IMMUNE MECHANISM 282.0 HEREDITARY SPHEROCYTOSIS 282.1 HEREDITARY ELLIPTOCYTOSIS 282.40 THALASSEMIA, UNSPECIFIED 282.43 ALPHA THALASSEMIA 282.44 BETA THALASSEMIA 282.45 DELTA-BETA THALASSEMIA 282.46 THALASSEMIA MINOR 282.47 HEMOGLOBIN E-BETA THALASSEMIA 282.5 SICKLE-CELL TRAIT 282.60-282.64 SICKLE-CELL DISEASE UNSPECIFIED - SICKLE-CELL/HB C DISEASE WITH CRISIS 282.68 OTHER SICKLE-CELL DISEASE WITHOUT CRISIS 282.69 OTHER SICKLE-CELL DISEASE WITH CRISIS 282.7 OTHER HEMOGLOBINOPATHIES 283.2 HEMOGLOBINURIA DUE TO HEMOLYSIS FROM EXTERNAL CAUSES 283.9 ACQUIRED HEMOLYTIC ANEMIA UNSPECIFIED
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 20 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 284.01 CONSTITUTIONAL RED BLOOD CELL APLASIA 284.09 OTHER CONSTITUTIONAL APLASTIC ANEMIA 284.11 ANTINEOPLASTIC CHEMOTHERAPY INDUCED PANCYTOPENIA 284.12 OTHER DRUG INDUCED PANCYTOPENIA 284.19 OTHER PANCYTOPENIA 284.2 MYELOPHTHISIS 284.81 RED CELL APLASIA (ACQUIRED) (ADULT) (WITH THYMOMA) 284.89 OTHER SPECIFIED APLASTIC ANEMIAS 284.9 APLASTIC ANEMIA UNSPECIFIED 285.0 SIDEROBLASTIC ANEMIA 285.22 ANEMIA IN NEOPLASTIC DISEASE 285.8-285.9 OTHER SPECIFIED ANEMIAS - ANEMIA UNSPECIFIED 287.1 QUALITATIVE PLATELET DEFECTS 287.30-287.33 PRIMARY THROMBOCYTOPENIA,UNSPECIFIED - CONGENITAL AND HEREDITARY THROMBOCYTOPENIC PURPURA 287.39 OTHER PRIMARY THROMBOCYTOPENIA 287.5 THROMBOCYTOPENIA UNSPECIFIED 288.00-288.04 NEUTROPENIA, UNSPECIFIED - NEUTROPENIA DUE TO INFECTION 288.09 OTHER NEUTROPENIA 288.1-288.4 FUNCTIONAL DISORDERS OF POLYMORPHONUCLEAR NEUTROPHILS - HEMOPHAGOCYTIC SYNDROMES 288.50-288.51 LEUKOCYTOPENIA, UNSPECIFIED - LYMPHOCYTOPENIA 288.59 OTHER DECREASED WHITE BLOOD CELL COUNT 288.60-288.65 LEUKOCYTOSIS, UNSPECIFIED BASOPHILIA 288.69 OTHER ELEVATED WHITE BLOOD CELL COUNT 288.8-288.9 OTHER SPECIFIED DISEASE OF WHITE BLOOD CELLS - UNSPECIFIED DISEASE OF WHITE BLOOD CELLS
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 21 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 289.4 HYPERSPLENISM 289.50-289.53 DISEASE OF SPLEEN UNSPECIFIED - NEUTROPENIC SPLENOMEGALY 289.59 OTHER DISEASES OF SPLEEN 289.83 MYELOFIBROSIS 289.9 UNSPECIFIED DISEASES OF BLOOD AND BLOOD- FORMING ORGANS 364.3 UNSPECIFIED IRIDOCYCLITIS 452 PORTAL VEIN THROMBOSIS 453.9 EMBOLISM AND THROMBOSIS OF UNSPECIFIED SITE 555.0-555.2 REGIONAL ENTERITIS OF SMALL INTESTINE - REGIONAL ENTERITIS OF SMALL INTESTINE WITH LARGE INTESTINE 555.9 REGIONAL ENTERITIS OF UNSPECIFIED SITE 556.0-556.6 ULCERATIVE (CHRONIC) ENTEROCOLITIS - UNIVERSAL ULCERATIVE (CHRONIC) COLITIS 556.9 ULCERATIVE COLITIS UNSPECIFIED 630 HYDATIDIFORM MOLE 696.0 PSORIATIC ARTHROPATHY 714.30 CHRONIC OR UNSPECIFIED POLYARTICULAR JUVENILE RHEUMATOID ARTHRITIS 720.0-720.2 ANKYLOSING SPONDYLITIS - SACROILIITIS NOT ELSEWHERE CLASSIFIED 720.81 INFLAMMATORY SPONDYLOPATHIES IN DISEASES CLASSIFIED ELSEWHERE 720.89 OTHER INFLAMMATORY SPONDYLOPATHIES 720.9 UNSPECIFIED INFLAMMATORY SPONDYLOPATHY 785.6 ENLARGEMENT OF LYMPH NODES 789.2 SPLENOMEGALY 789.30-789.37 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP UNSPECIFIED SITE - ABDOMINAL OR PELVIC SWELLING MASS OR LUMP GENERALIZED
Medicare Local Coverage Determination Policy LA Flow Cytometry (L33526) (Page 22 of 22) Testing performed by Quest Diagnostics Nichols Institute CPT Codes: 88182, 88184, 88185, 88187, 88188, 88189 LCD Description: Flow cytometry (FCM) is a complex process to examine blood, body fluids, CSF, bone marrow, lymph node, tonsil, spleen and other solid tissues. The use of peripheral blood and fine needle aspirate material avoids more invasive procedures for diagnosis. A flow cytometer evaluates the physical and/or chemical characteristics of single cells as the cells pass individually in a fluid stream through a measuring device. Surface receptors, intracellular molecules, and DNA bind with fluorescent dyes that allow detection and evaluation. When light of one wave length excites electrons of certain chemicals to energy levels above their ground state and upon return to ground state emits light of a longer wavelength, fluorescence is produced. A flow cytometer detects cell characteristics by measuring the fluorescence produced by fluorochromes conjugated either directly with cell components or conjugated to antibodies directed against cell components. Limitations: Since FCM immunophenotypes for most common lymphomas and leukemias are well characterized, Noridian does NOT consider it reasonable and necessary to perform more than 24 markers in a panel. When atypical or unusual FCM results are obtained, the selective addition of more markers may be indicated. The flow report must document the specific indication for each marker over the 24 marker limit. The FCM report must document the specific indication for each marker over the 24-marker limit. FCM reports without clear justification for each marker over 24 will be denied. 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 Medical Local Coverage Determination Policy. An ICD-9-CM book should be used as a complete reference. 789.39 ABDOMINAL OR PELVIC SWELLING MASS OR LUMP OTHER SPECIFIED SITE 791.0 PROTEINURIA 795.4 OTHER NONSPECIFIC ABNORMAL HISTOLOGICAL FINDINGS 996.80-996.87 COMPLICATIONS OF UNSPECIFIED TRANSPLANTED ORGAN - COMPLICATIONS OF TRANSPLANTED ORGAN INTESTINE 996.88 COMPLICATIONS OF TRANSPLANTED ORGAN, STEM CELL 996.89 COMPLICATIONS OF OTHER SPECIFIED TRANSPLANTED ORGAN V08 ASYMPTOMATIC HUMAN IMMUNODEFICIENCY VIRUS (HIV) INFECTION STATUS V10.60 - V10.63 PERSONAL HISTORY OF UNSPECIFIED LEUKEMIA - PERSONAL HISTORY OF MONOCYTIC LEUKEMIA V10.69 PERSONAL HISTORY OF OTHER LEUKEMIA V42.0 - V42.7 KIDNEY REPLACED BY TRANSPLANT - LIVER REPLACED BY TRANSPLANT V42.81 - 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 V49.83 AWAITING ORGAN TRANSPLANT STATUS V58.44 AFTERCARE FOLLOWING ORGAN TRANSPLANT V71.1 OBSERVATION FOR SUSPECTED MALIGNANT NEOPLASM
L32731 Frequency of Laboratory Tests Glucose Testing CPT Codes: 82948, 82962 LCD Description: This LCD imposes utilization guideline limitations. Despite Medicare's allowing up to these maximums, each patient s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services. LCD Frequency Limit: Once per month. Acceptable Reasons (ICD-9-CM Codes) for Exceeding the LCD Maximum: Uncontrolled Diabetes MellitusThyrotoxicosis Codes pertaining to the above bullets: 250.02-250.03 250.92-250.93 05/01/13
Medicare Local Coverage Determination Policy LA L32731 Frequency of Laboratory Tests - Lipids CPT Codes: 80061, 82465, 83718, 83721, 84478 LCD Description: This LCD imposes utilization guideline limitations. Despite Medicare's allowing up to these maximums, each patient s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services. LCD Frequency Limit: No more than every two months for any test (e.g. triglycerides, LDL cholesterol), whether ordered in a panel or separately ordered. Acceptable Reasons (ICD-9-CM Codes) for Exceeding the LCD Maximum: 577.0 577.1 Pancreatitis V58,69 Inability To Stabilize Lipid-Lowering Drug Dosing V58.69 Adverse Reaction To Lipid-Lowering Drug 05/01/13
L32731 Frequency of Laboratory Tests Thyroid Testing CPT Codes: 84436, 84439, 84443, 84479 LCD Description: This LCD imposes utilization guideline limitations. Despite Medicare's allowing up to these maximums, each patient s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services. LCD Frequency Limit: Four times a year for most patients, except for selected endocrine presentations. Acceptable Reasons (ICD-9-CM Codes) for Exceeding the LCD Maximum: Inability To Stabilize Thyroid Medication Dosing Thyrotoxicosis Concurrent Endocrinopathies Hypothyroidism Codes pertaining to the above bullets: 226 242.00 242.91 243 244.0 244.3 244.8 244.9 245.0 245.4 245.8 245.9 250.00 250.03 250.10 250.13 250.20 250.23 250.30 250.33 250.40 250.43 250.50 250.53 250.60 250.63 250.70 250.73 250.80 250.83 250.90 250.93 252.1 253.2 253.4 255.2 255.41 255.42 272.0 272.2 275.40 275.42 275.49 276.0 276.1 279.4 281.0 281.9 285.9 290.0 290.10 290.13 290.20 290.21 290.3 293.0 293.1 296.00 296.06 296.10 296.16 296.20 296.26 296.30 296.36 296.40 296.46 296.50 296.56 296.60 296.66 296.7 296.80 296.82 296.89 296.90 296.99 300.00 300.02 300.09 311 359.5 374.41 374.82 376.21 376.22 427.0 427.31 428.0 511.9 560.1 625.3 750.15 780.02 780.09 783.1 783.21 784.1 785.0 785.1 794.5 V58.69 05/01/13
Medicare Local Coverage Determination Policy - LA L33644 Molecular Diagnostics: Genitourinary Infectious Disease esting T (Page 1 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are 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. 076.0-076.1 Trachoma Initial Stage - Trachoma Active Stage 076.9 Trachoma Unspecified 077.0 Inclusion Conjunctivitis 077.98-077.99 Unspecified Diseases Of Conjunctiva Due To Chlamydiae - Unspecified Diseases Of Conjunctiva Due To Viruses 098.0 Gonococcal Infection (Acute) Of Lower Genitourinary Tract 098.10-098.17 Gonococcal Infection (Acute) Of Upper Genitourinary Tract Site Unspecified - Gonococcal Salpingitis Specified As Acute 098.19 Other Gonococcal Infection (Acute) Of Upper Genitourinary Tract 098.2 Gonococcal Infection Chronic Of Lower Genitourinary Tract 098.30-098.37 Chronic Gonococcal Infection Of Upper Genitourinary Tract Site Unspecified - Gonococcal Salpingitis (Chronic) 098.39 Other Chronic Gonococcal Infection Of Upper Genitourinary Tract 098.40-098.43 Gonococcal Conjunctivitis (Neonatorum) - Gonococcal Keratitis 098.49 Other Gonococcal Infection Of Eye 098.50-098.53 Gonococcal Arthritis - Gonococcal Spondylitis 098.59 Other Gonococcal Infection Of Joint 12/05/13
Medicare Local Coverage Determination Policy - LA L33644 Molecular Diagnostics: Genitourinary Infectious Disease esting T (Page 2 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are 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. 098.6-098.7 Gonococcal Infection Of Pharynx - Gonococcal Infection Of Anus And Rectum 098.81-098.86 Gonococcal Keratosis (Blennorrhagica) - Gonococcal Peritonitis 098.89 Gonococcal Infection Of Other Specified Sites 099.1 Lymphogranuloma Venereum 099.3 Reiter's Disease 099.41 Other Nongonococcal Urethritis Chlamydia Trachomatis 099.50-099.56 Other Venereal Diseases Due To Chlamydia Trachomatis Unspecified Site - Other Venereal Diseases Due To Chlamydia Trachomatis Peritoneum 099.59 Other Venereal Diseases Due To Chlamydia Trachomatis Other Specified Site 112.1-112.2 Candidiasis Of Vulva And Vagina - Candidiasis Of Other Urogenital Sites 131.00-131.03 Urogenital Trichomoniasis Unspecified - Trichomonal Prostatitis 131.09 Other Urogenital Trichomoniasis 131.8-131.9 Trichomoniasis Of Other Specified Sites - Trichomoniasis Unspecified 288.00-288.04 Neutropenia, Unspecified - Neutropenia Due To Infection 288.09 Other Neutropenia 288.66 Bandemia 288.8 Other Specified Disease Of White Blood Cells 12/05/13
Medicare Local Coverage Determination Policy - LA L33644 Molecular Diagnostics: Genitourinary Infectious Disease esting T (Page 3 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are 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. 289.1 Chronic Lymphadenitis 289.53 Neutropenic Splenomegaly 289.83 Myelofibrosis 372.00 Acute Conjunctivitis Unspecified 372.02-372.03 Acute Follicular Conjunctivitis - Other Mucopurulent Conjunctivitis 372.10-372.12 Chronic Conjunctivitis Unspecified - Chronic Follicular Conjunctivitis 595.4 Cystitis In Diseases Classified Elsewhere 597.80-597.81 Urethritis Unspecified - Urethral Syndrome Nos 601.0 Acute Prostatitis 601.8-601.9 Other Specified Inflammatory Diseases Of Prostate - Prostatitis Unspecified 604.0 Orchitis Epididymitis And Epididymo-Orchitis With Abscess 604.90-604.91 Orchitis And Epididymitis Unspecified - Orchitis And Epididymitis In Diseases Classified Elsewhere 608.89 Other Specified Disorders Of Male Genital Organs 614.0 Acute Salpingitis And Oophoritis 614.2-614.4 Salpingitis And Oophoritis Not Specified As Acute Subacute Or Chronic - Chronic Or Unspecified Parametritis And Pelvic Cellulitis 614.6 Pelvic Peritoneal Adhesions Female (Postoperative) (Postinfection) 12/05/13
Medicare Local Coverage Determination Policy - LA L33644 Molecular Diagnostics: Genitourinary Infectious Disease esting T (Page 4 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are 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. 614.8-614.9 Other Specified Inflammatory Disease Of Female Pelvic Organs And Tissues - Unspecified Inflammatory Disease Of Female Pelvic Organs And Tissues 616.0 Cervicitis And Endocervicitis 616.10 Vaginitis And Vulvovaginitis Unspecified 616.11 Vaginitis And Vulvovaginitis In Diseases Classified Elsewhere 616.2 Cyst Of Bartholin's Gland 616.3 Abscess Of Bartholin's Gland 616.4 Other Abscess Of Vulva 616.50 Ulceration Of Vulva Unspecified 616.51 Ulceration Of Vulva In Diseases Classified Elsewhere 616.81 Mucositis (Ulcerative) Of Cervix, Vagina, And Vulva 616.89 Other Inflammatory Disease Of Cervix, Vagina And Vulva 616.9 Unspecified Inflammatory Disease Of Cervix Vagina And Vulva 628.2 Infertility Female Of Tubal Origin 629.89 Other Specified Disorders Of Female Genital Organs 683 Acute Lymphadenitis 12/05/13
Medicare Local Coverage Determination Policy LA L33644 Molecular Diagnostics: Genitourinary Infectious Disease Test ing (Page 5 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are 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. 711.90-711.99 Unspecified Infective Arthritis Site Unspecified - Unspecified Infective Arthritis Involving Multiple Sites 716.50-716.59 Unspecified Polyarthropathy Or Polyarthritis Site Unspecified - Unspecified Polyarthropathy Or Polyarthritis Involving Multiple Sites 716.60-716.68 Unspecified Monoarthritis Site Unspecified - Unspecified Monoarthritis Involving Other Specified Sites 716.90-716.99 Unspecified Arthropathy Site Unspecified - Unspecified Arthropathy Involving Multiple Sites 719.40-719.49 Pain In Joint Site Unspecified - Pain In Joint Involving Multiple Sites 727.00 Synovitis And Tenosynovitis Unspecified 727.05-727.06 Other Tenosynovitis Of Hand And Wrist - Tenosynovitis Of Foot And Ankle 727.09 Other Synovitis And Tenosynovitis 771.6 Neonatal Conjunctivitis And Dacryocystitis 780.60-780.61 Fever, Unspecified - Fever Presenting With Conditions Classified Elsewhere 782.1 Rash And Other Nonspecific Skin Eruption 785.6 Enlargement Of Lymph Nodes 788.1 Dysuria 788.64-788.65 Urinary Hesitancy - Straining On Urination 788.7 Urethral Discharge 789.00-789.07 Abdominal Pain Unspecified Site - Abdominal Pain Generalized 12/05/13
Medicare Local Coverage Determination Policy LA L33644 Molecular Diagnostics: Genitourinary Infectious Disease Test ing (Page 6 of 7) CPT Codes: 87480, 87490, 87491, 87510, 87590, 87591, 87660 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are 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. 711.90-711.99 Unspecified Infective Arthritis Site Unspecified - Unspecified Infective Arthritis Involving Multiple Sites 716.50-716.59 Unspecified Polyarthropathy Or Polyarthritis Site Unspecified - Unspecified Polyarthropathy Or Polyarthritis Involving Multiple Sites 716.60-716.68 Unspecified Monoarthritis Site Unspecified - Unspecified Monoarthritis Involving Other Specified Sites 716.90-716.99 Unspecified Arthropathy Site Unspecified - Unspecified Arthropathy Involving Multiple Sites 719.40-719.49 Pain In Joint Site Unspecified - Pain In Joint Involving Multiple Sites 727.00 Synovitis And Tenosynovitis Unspecified 727.05-727.06 Other Tenosynovitis Of Hand And Wrist - Tenosynovitis Of Foot And Ankle 727.09 Other Synovitis And Tenosynovitis 771.6 Neonatal Conjunctivitis And Dacryocystitis 780.60-780.61 Fever, Unspecified - Fever Presenting With Conditions Classified Elsewhere 782.1 Rash And Other Nonspecific Skin Eruption 785.6 Enlargement Of Lymph Nodes 788.1 Dysuria 788.64-788.65 Urinary Hesitancy - Straining On Urination 788.7 Urethral Discharge 789.00-789.07 Abdominal Pain Unspecified Site - Abdominal Pain Generalized 12/05/13
Medicare Local Coverage Determination Policy LA L33644 Molecular Diagnostics: Genitourinary Infectious Disease Testing (Page 7 of 7) CPT Codes: 87481, 87798 LCD Description: Molecular diagnostic testing provides sensitive, specific and timely (i.e., relative to that of traditional culture-based methods) identification of diverse biological entities, including microorganisms and tumors. The current LCD will focus upon coverage of the more prevalent (typical) bacterial and fungal organisms (per the eight organism-specific CPT codes, ranging from 87480 to 87660) which are encountered for the majority of gynecological infectious presentations. Conversely, there are less typically encountered (rare) pathogens for which genitourinary (GU) microbiological evaluations (i.e., sometimes including panel testing) are less well-established and even investigational. In this context, medical review, educational outreach, etc. will be conducted on an as-needed basis. Utilization Guidelines: No more than two individual microorganisms may be concurrently billed for CPT 87481 and 87798. ICD-9-CM Codes that Support Medical Necessity Genitourinary Infectious Disease tests are determined to be medically necessary by Medicare only when they are 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. 87481 and 87798 are considered on a case by case basis. 12/05/13
L34352 Qualitative Drug Screening (Page 1 of 2) CPT Codes: G0431, G0434 LCD Description: A qualitative drug screen may be indicated with a symptomatic patient when the history is unreliable, with a multiple-drug ingestion, with a patient in delirium or coma, for the identification of specific drugs, and to indicate when antagonists may be used. The clinical utility of drug screens in the emergency setting may be limited because patient management decisions are unaffected since most therapy for drug poisonings is symptom directed and supportive. Utilization Guidelines: Drug screening for medico-legal purposes (e.g., court-ordered drug screening) or for employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment) is not covered. ICD-9-CM Codes that Support Medical Necessity The Qualitative Drug Screening 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. 276.2 Acidosis 295.00 Simple Type Schizophrenia Unspecified State 295.10 Disorganized Type Schizophrenia Unspecified State 295.20 Catatonic Type Schizophrenia Unspecified State 295.30 Paranoid Type Schizophrenia Unspecified State 304.01 Opioid Type Dependence Continuous Use 304.90 Unspecified Drug Dependence Unspecified Use 305.90 Other Mixed Or Unspecified Drug Abuse Unspecified Use 345.10 Generalized Convulsive Epilepsy Without Intractable Epilepsy 345.11 Generalized Convulsive Epilepsy With Intractable Epilepsy 345.3 Grand Mal Status Epileptic 345.90 Epilepsy Unspecified Without Intractable Epilepsy 345.91 Epilepsy Unspecified With Intractable Epilepsy 426.10 Atrioventricular Block Unspecified 426.11 First Degree Atrioventricular Block 426.12 Mobitz (Type) Ii Atrioventricular Block 426.13 Other Second Degree Atrioventricular Block 426.82 Long Qt Syndrome 427.0 Paroxysmal Supraventricular Tachycardia 427.1 Paroxysmal Ventricular Tachycardia 780.01 Coma 780.09 Alteration Of Consciousness Other 780.1 Hallucinations 780.39 Other Convulsions 780.97 Altered Mental Status 963.0 Poisoning By Antiallergic And Antiemetic Drugs 965.00 Poisoning By Opium (Alkaloids) Unspecified 965.01 Poisoning By Heroin 965.02 Poisoning By Methadone 965.09 Poisoning By Other Opiates And Related Narcotics 965.1 Poisoning By Salicylates 965.4 Poisoning By Aromatic Analgesics Not Elsewhere Classified 965.5 Poisoning By Pyrazole Derivatives 965.61 Poisoning By Propionic Acid Derivatives 966.1 Poisoning By Hydantoin Derivatives 967.0 Poisoning By Barbiturates 03/25/13
L34352 Qualitative Drug Screening (Page 2 of 2) CPT Codes: G0431, G0434 LCD Description: A qualitative drug screen may be indicated with a symptomatic patient when the history is unreliable, with a multiple-drug ingestion, with a patient in delirium or coma, for the identification of specific drugs, and to indicate when antagonists may be used. The clinical utility of drug screens in the emergency setting may be limited because patient management decisions are unaffected since most therapy for drug poisonings is symptom directed and supportive. Utilization Guidelines: Drug screening for medico-legal purposes (e.g., court-ordered drug screening) or for employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment) is not covered. ICD-9-CM Codes that Support Medical Necessity The Qualitative Drug Screening 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. 967.1 Poisoning By Chloral Hydrate Group 967.2 Poisoning By Paraldehyde 967.2 Poisoning By Paraldehyde 967.3 Poisoning By Bromine Compounds 967.4 Poisoning By Methaqualone Compounds 967.5 Poisoning By Glutethimide Group 967.6 Poisoning By Mixed Sedatives Not Elsewhere Classified 967.8 Poisoning By Other Sedatives And Hypnotics 967.9 Poisoning By Unspecified Sedative Or Hypnotic 969.00 Poisoning By Antidepressant, Unspecified 969.01 Poisoning By Monoamine Oxidase Inhibitors 969.02 Poisoning By Selective Serotonin And Norepinephrine Reuptake Inhibitors 969.03 Poisoning By Selective Serotonin Reuptake Inhibitors 969.04 Poisoning By Tetracyclic Antidepressants 969.05 Poisoning By Tricyclic Antidepressants 969.09 Poisoning By Other Antidepressants 969.1 Poisoning By Phenothiazine-Based Tranquilizers 969.2 Poisoning By Butyrophenone-Based Tranquilizers 969.3 Poisoning By Other Antipsychotics Neuroleptics And Major Tranquilizers 969.4 Poisoning By Benzodiazepine-Based Tranquilizers 969.5 Poisoning By Other Tranquilizers 969.6 Poisoning By Psychodysleptics (Hallucinogens) 969.70 Poisoning By Psychostimulant, Unspecified 969.71 Poisoning By Caffeine 969.72 Poisoning By Amphetamines 969.73 Poisoning By Methylphenidate 969.79 Poisoning By Other Psychostimulants 969.8 Poisoning By Other Specified Psychotropic Agents 969.9 Poisoning By Unspecified Psychotropic Agent 970.81 Poisoning By Cocaine 970.89 Poisoning By Other Central Nervous System Stimulants 972.1 Poisoning By Cardiotonic Glycosides And Drugs Of Similar Action 977.9 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 03/25/13
Medicare Local Coverage Determination Policy LA L31686 Services That Are Not Reasonable and Necessary CPT Codes: 83179 LCD Description: Inclusion of a service or procedure in this non-coverage LCD indicates that the service is considered to be not reasonable and necessary and claims reporting the service will be denied as such. Lipoprotein, direct measurement; VLDL cholesterol (procedure code 83719) is considered a non-covered code. NCEP recommendations do not include monitoring of VLDL levels for treatment of elevated cholesterol as risk factors for coronary and vascular atherosclerosis. Non-Covered Codes 83719 Assay of blood lipoprotein