Covered for:
003.21
|
Salmonella meningitis
|
|
013.00–013.06
|
Tuberculous meningitis
|
|
013.40–013.46
|
Tuberculoma of spinal cord
|
|
013.50–013.56
|
Tuberculous abscess of spinal cord
|
|
013.60–013.66
|
Tuberculous encephalitis or myelitis
|
|
015.00–015.06
|
Tuberculosis of vertebral column
|
|
045.00–045.03
|
Acute paralytic poliomyelitis specified as bulbar
|
|
045.10–045.13
|
Acute poliomyelitis with other paralysis
|
|
045.20–045.23
|
Acute non-paralytic poliomyelitis
|
|
045.90–045.93
|
Acute poliomyelitis, unspecified
|
|
091.81
|
Acute syphilitic meningitis (secondary)
|
|
094.0–094.3
|
Neurosyphilis
|
|
094.81–094.87
|
Other specified neurosyphilis
|
|
094.89
|
Other specified neurosyphilis, other
|
|
094.9
|
Neurosyphilis, unspecified
|
|
098.82
|
Gonococcal meningitis
|
|
100.81
|
Leptospiral meningitis (aseptic)
|
|
112.83
|
Candidal meningitis
|
|
114.2
|
Coccidioidal meningitis
|
|
115.01
|
Histoplasma capsulatum meningitis
|
|
115.11
|
Histoplasma duboisii meningitis
|
|
130.0
|
Meningoencephalitis due to toxoplasmosis
|
|
140.0–140.1
|
Malignant neoplasm of lip
|
|
140.3–140.6
|
Malignant neoplasm of lip
|
|
140.8–140.9
|
Malignant neoplasm of lip
|
|
141.0–141.6
|
Malignant neoplasm of tongue
|
|
141.8–141.9
|
Malignant neoplasm of tongue
|
|
142.0–142.2
|
Malignant neoplasm of major salivary glands
|
|
142.8–142.9
|
Malignant neoplasm of major salivary glands
|
|
143.0–143.1
|
Malignant neoplasm of gum
|
|
143.8–143.9
|
Malignant neoplasm of gum
|
|
144.0–144.1
|
Malignant neoplasm of floor of mouth
|
|
144.8–144.9
|
Malignant neoplasm of floor of mouth
|
|
145.0–145.6
|
Malignant neoplasm of other and unspecified parts of mouth
|
|
145.8–145.9
|
Malignant neoplasm of other and unspecified parts of mouth
|
|
146.0–146.9
|
Malignant neoplasm of oropharynx
|
|
147.0–147.3
|
Malignant neoplasm of nasopharynx
|
|
147.8–147.9
|
Malignant neoplasm of nasopharynx
|
|
148.0–148.3
|
Malignant neoplasm of hypopharynx
|
|
148.8–148.9
|
Malignant neoplasm of hypopharynx
|
|
149.0–149.1
|
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
|
|
149.8–149.9
|
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
|
|
150.0–150.5
|
Malignant neoplasm of esophagus
|
|
150.8 -150.9
|
Malignant neoplasm of esophagus
|
|
151.0–151.6
|
Malignant neoplasm of stomach
|
|
151.8–151.9
|
Malignant neoplasm of stomach
|
|
152.0–152.3
|
Malignant neoplasm of small intestine, including duodenum
|
|
152.8–152.9
|
Malignant neoplasm of small intestine, including duodenum
|
|
153.0–153.9
|
Malignant neoplasm of colon
|
|
154.0–154.3
|
Malignant neoplasm of rectum, rectosigmoid junction, and anus
|
|
154.8
|
Malignant neoplasm of anus unspecified
|
|
155.0–155.2
|
Malignant neoplasm of liver and intrahepatic bile ducts
|
|
156.0–156.2
|
Malignant neoplasm of gallbladder and extrahepatic bile ducts
|
|
156.8–156.9
|
Malignant neoplasm of gallbladder and extrahepatic bile ducts
|
|
157.0–157.4
|
Malignant neoplasm of pancreas
|
|
157.8–157.9
|
Malignant neoplasm of pancreas
|
|
158.0
|
Malignant neoplasm of retroperitoneum
|
|
158.8
|
Malignant neoplasm of specified parts of peritoneum
|
|
159.0–159.1
|
Malignant neoplasm of other and ill-defined sites within the digestive organs and peritoneum
|
|
159.8–159.9
|
Malignant neoplasm of other and ill-defined sites within the digestive organs and peritoneum
|
|
160.0–160.5
|
Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
|
|
160.8–160.9
|
Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
|
|
161.0–161.3
|
Malignant neoplasm of larynx
|
|
161.8–161.9
|
Malignant neoplasm of larynx
|
|
162.0
|
Malignant neoplasm of trachea
|
|
162.2–162.5
|
Malignant neoplasm of trachea, bronchus, and lung
|
|
162.8–162.9
|
Malignant neoplasm of trachea, bronchus, and lung
|
|
163.0–163.1
|
Malignant neoplasm of pleura
|
|
163.8–163.9
|
Malignant neoplasm of pleura
|
|
164.0–164.3
|
Malignant neoplasm of thymus, heart, and mediastinum
|
|
164.8–164.9
|
Malignant neoplasm of thymus, heart, and mediastinum
|
|
165.0
|
Malignant neoplasm of upper respiratory tract, part unspecified
|
|
165.8–165.9
|
Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs
|
|
170.0–170.9
|
Malignant neoplasm of bone and articular cartilage
|
|
171.0
|
Malignant neoplasm of connective and other soft tissue, head, face and neck
|
|
171.2–171.9
|
Malignant neoplasm of connective and other soft tissue
|
|
172.0–172.9
|
Malignant melanoma of skin
|
|
173.0–173.9
|
Other malignant neoplasm of skin
|
|
174.0–174.6
|
Malignant neoplasm of female breast
|
|
174.8–174.9
|
Malignant neoplasm of female breast
|
|
175.0
|
Malignant neoplasm of male breast, nipple and areola
|
|
175.9
|
Malignant neoplasm of other and unspecified sites of male breast
|
|
176.0–176.5
|
Kaposi’s sarcoma
|
|
176.8–176.9
|
Kaposi’s sarcoma
|
|
179
|
Malignant neoplasm of uterus, part unspecified
|
|
180.0–180.1
|
Malignant neoplasm of cervix uteri
|
|
180.8–180.9
|
Malignant neoplasm of cervix uteri
|
|
181
|
Malignant neoplasm of placenta
|
|
182.0–182.1
|
Malignant neoplasm of body of uterus
|
|
182.8
|
Malignant neoplasm of other specified site of body of uterus
|
|
183.0
|
Malignant neoplasm of ovary
|
|
183.2–183.5
|
Malignant neoplasm of ovary and other uterine adnexa
|
|
183.8–183.9
|
Malignant neoplasm of ovary and other uterine adnexa
|
|
184.0–184.4
|
Malignant neoplasm of other and unspecified female genital organs
|
|
184.8–184.9
|
Malignant neoplasm of other and unspecified female genital organs
|
|
185
|
Malignant neoplasm of prostate
|
|
186.0
|
Malignant neoplasm of undescended testis
|
|
186.9
|
Malignant neoplasm of other and unspecified testis
|
|
187.1–187.9
|
Malignant neoplasm of penis and other male genital organs
|
|
188.0–188.9
|
Malignant neoplasm of bladder
|
|
189.0–189.4
|
Malignant neoplasm of kidney and other and unspecified urinary organs
|
|
189.8–189.9
|
Malignant neoplasm of kidney and other and unspecified urinary organs
|
|
190.0–190.9
|
Malignant neoplasm of eye
|
|
192.1–192.3
|
Malignant neoplasm of cerebral meninges, spinal cord, and spinal meninges
|
|
193
|
Malignant neoplasm of thyroid gland
|
|
194.6
|
Malignant neoplasm of aortic body and other paraganglia
|
|
195.0–195.5
|
Malignant neoplasm of other and ill-defined sites
|
|
195.8
|
Malignant neoplasm of other specified sites
|
|
196.0–196.3
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
|
196.5–196.6
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
|
196.8–196.9
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
|
197.0–197.8
|
Secondary malignant neoplasm of respiratory and digestive systems
|
|
198.0*–198.7*
|
Secondary malignant neoplasm of other specified sites
|
|
198.81*–198.82*
|
Secondary malignant neoplasm of other specified sites
|
|
198.89*
|
Secondary malignant neoplasm of other specified sites
|
|
Note: Use 198.XX range of codes to indicate metastases to the spinal column.
|
||
199.0–199.2
|
Malignant neoplasm without specification of site
|
|
200.00–200.08
|
Reticulosarcoma
|
|
200.10–200.18
|
Lymphosarcoma
|
|
200.20–200.28
|
Burkitt’s tumor or lymphoma
|
|
200.30–200.38
|
Marginal zone lymphoma
|
|
200.40–200.48
|
Mantle cell lymphoma
|
|
200.50–200.58
|
Primary central nervous system lymphoma
|
|
200.60–200.68
|
Anaplastic large cell lymphoma
|
|
200.70–200.78
|
Large cell lymphoma
|
|
200.80–200.88
|
Lymphosarcoma and reticulosarcoma, other named variants
|
|
201.00–201.08
|
Hodgkin’s paragranuloma
|
|
201.10–201.18
|
Hodgkin’s granuloma
|
|
201.20–201.28
|
Hodgkin’s sarcoma
|
|
201.40–201.48
|
Hodgkin’s disease, lymphocytic-histiocytic predominance
|
|
201.50–201.58
|
Hodgkin’s disease, nodular sclerosis
|
|
201.60–201.68
|
Hodgkin’s disease, mixed cellularity
|
|
201.70–201.78
|
Hodgkin’s disease, lymphocytic depletion
|
|
201.90–201.98
|
Hodgkin’s disease, unspecified
|
|
202.00–202.08
|
Nodular lymphoma
|
|
202.10–202.18
|
Mycosis fungoides
|
|
202.20–202.28
|
Sezary’s disease
|
|
202.30–202.38
|
Malignant histiocytosis
|
|
202.40–202.48
|
Leukemic reticuloendotheliosis
|
|
202.50–202.58
|
Letterer-Siwe disease
|
|
202.60–202.68
|
Malignant mast cell tumors
|
|
202.70–202.78
|
Peripheral T cell lymphoma
|
|
202.80–202.88
|
Other lymphomas
|
|
202.90–202.98
|
Other and unspecified malignant neoplasms of lymphoid and histocytic tissue
|
|
203.00–203.02
|
Multiple myeloma
|
|
203.10–203.12
|
Plasma cell leukemia
|
|
203.80–203.82
|
Other immunoproliferative neoplasms
|
|
204.00–204.02
|
Acute lymphoid leukemia
|
|
204.10–204.12
|
Chronic lymphoid leukemia
|
|
204.20–204.22
|
Subacute lymphoid leukemia
|
|
204.80–204.82
|
Other lymphoid leukemia
|
|
204.90–204.92
|
Unspecified lymphoid leukemia
|
|
205.00–205.02
|
Acute myeloid leukemia
|
|
205.10–205.12
|
Chronic myeloid leukemia
|
|
205.20–205.22
|
Subacute myeloid leukemia
|
|
205.30–205.32
|
Myeloid sarcoma
|
|
205.80–205.82
|
Other myeloid leukemia
|
|
205.90–205.92
|
Unspecified myeloid leukemia
|
|
206.00–206.02
|
Acute monocytic leukemia
|
|
206.10–206.12
|
Chronic monocytic leukemia
|
|
206.20–206.22
|
Subacute monocytic leukemia
|
|
206.80–206.82
|
Other monocytic leukemia
|
|
206.90–206.92
|
Unspecified monocytic leukemia
|
|
207.00–207.02
|
Acute erythremia and erythroleukemia
|
|
207.10–207.12
|
Chronic erythremia
|
|
207.20–207.22
|
Megakaryocytic leukemia
|
|
207.80–207.82
|
Other specified leukemia
|
|
208.00–208.02
|
Acute leukemia of unspecified cell type
|
|
208.10–208.12
|
Chronic leukemia of unspecified cell type
|
|
208.20–208.22
|
Subacute leukemia of unspecified cell type
|
|
208.80–208.82
|
Other leukemia of unspecified cell type
|
|
208.90–208.92
|
Unspecified leukemia of unspecified cell type
|
|
213.2
|
Benign neoplasm of vertebral column, excluding sacrum and coccyx
|
|
213.9
|
Benign neoplasm of bone and articular cartilage, site unspecified
|
|
215.8–215.9
|
Other benign neoplasm of connective and other soft tissue
|
|
225.3–225.4
|
Benign neoplasm of other parts of nervous system
|
|
225.8–225.9
|
Benign neoplasm of other parts of nervous system
|
|
227.6
|
Benign neoplasm of aortic body and other paraganglia
|
|
228.00
|
Hemangioma of unspecified site
|
|
228.09
|
Hemangioma of other sites
|
|
237.3
|
Neoplasm of uncertain behavior of paraganglia
|
|
237.5–237.6
|
Neoplasm of uncertain behavior of endocrine glands and nervous system
|
|
237.70–237.73
|
Neurofibromatosis
|
|
237.79
|
Other neurofibromatosis
|
|
237.9
|
Neoplasm of uncertain behavior of other and unspecified parts of nervous system
|
|
238.0–238.1
|
Neoplasm of uncertain behavior of other and unspecified sites and tissues
|
|
238.6
|
Neoplasm of uncertain behavior of plasma cells
|
|
238.72–238.75
|
Neoplasm of uncertain behavior of other lymphatic and hematopoietic tissues
|
|
239.2
|
Neoplasm of unspecified nature of bone, soft tissue, and skin
|
|
239.6–239.7
|
Neoplasm of unspecified nature
|
|
239.89
|
Neoplasms of unspecified nature, other specified sites
|
|
320.0–320.3
|
Bacterial meningitis
|
|
320.7
|
Meningitis in other bacterial diseases classified elsewhere
|
|
320.81–320.82
|
Meningitis due to other specified bacteria
|
|
320.89
|
Meningitis due to other specified bacteria
|
|
320.9
|
Meningitis due to unspecified bacterium
|
|
321.0–321.4
|
Meningitis due to other organisms
|
|
321.8
|
Meningitis due to other non-bacterial organisms classified elsewhere
|
|
322.0–322.2
|
Meningitis of unspecified cause
|
|
322.9
|
Meningitis, unspecified
|
|
323.01–323.02
|
Encephalitis, myelitis, and encephalomyelitis in viral diseases, classified elsewhere
|
|
323.1–323.2
|
Encephalitis, myelitis, and encephalomyelitis
|
|
323.41–323.42
|
Other encephalitis, myelitis, and encephalomyelitis due to infection, classified elsewhere
|
|
323.52
|
Myelitis following immunization procedures
|
|
323.61–323.63
|
Postinfectious encephalitis, myelitis, and encephalomyelitis
|
|
323.71–323.72
|
Toxic encephalitis and encephalomyelitis – Toxic myelitis
|
|
323.81–323.82
|
Other causes of encephalitis, myelitis, and encephalomyelitis
|
|
323.9
|
Unspecified cause of encephalitis
|
|
324.1
|
Intraspinal abscess
|
|
326*
|
Late effects of intracranial abscess or pyogenic infection
|
|
Note: Use 326 to indicate late effects of syringomyelitis.
|
||
335.20–335.24
|
Motor neuron disease
|
|
335.29
|
Other motor neuron diseases
|
|
336.0–336.3
|
Other diseases of spinal cord
|
|
336.8*–336.9*
|
Other diseases of spinal cord
|
|
Note: Use 336.8 or 336.9 to indicate cord compression.
|
||
340
|
Multiple sclerosis
|
|
341.0–341.1
|
Other demyelinating diseases of central nervous system
|
|
341.8–341.9
|
Other demyelinating diseases of central nervous system
|
|
343.0–343.4
|
Infantile cerebral palsy
|
|
344.00–344.04
|
Other paralytic syndromes
|
|
344.09
|
Other quadriplegia
|
|
344.89
|
Other specified paralytic syndrome
|
|
349.1–349.2
|
Other and unspecified disorders of the nervous system
|
|
349.31
|
Accidental puncture or laceration of dura during a procedure
|
|
349.39
|
Other dural tear
|
|
353.3
|
Thoracic root lesions, not elsewhere classified
|
|
442.89*
|
Aneurysm of other specified site
|
|
Note: Use 442.89to indicate aneurysm of spinal artery.
|
||
720.0
|
Ankylosing spondylitis
|
|
720.81
|
Inflammatory spondylopathies in diseases classified elsewhere
|
|
721.41
|
Spondylosis with myelopathy, thoracic region
|
|
721.91
|
Spondylosis of unspecified site with myelopathy
|
|
722.11
|
Displacement of thoracic intervertebral disc without myelopathy
|
|
722.2
|
Displacement of intervertebral disc, site unspecified, without myelopathy
|
|
722.51
|
Degeneration of thoracic or thoracolumbar intervertebral disc
|
|
722.72
|
Intervertebral disc disorder with myelopathy, thoracic region
|
|
722.82
|
Postlaminectomy syndrome of thoracic region
|
|
722.92
|
Other and unspecified disc disorder of thoracic region
|
|
724.00–724.01
|
Spinal stenosis , other than cervical
|
|
724.4
|
Thoracic or lumbosacral neuritis or radiculitis, unspecified
|
|
730.08
|
Acute osteomyelitis involving other specified sites
|
|
730.18
|
Chronic osteomyelitis involving other specified sites
|
|
732.0
|
Juvenile osteochondrosis of spine
|
|
733.00–733.03
|
Other disorders of bone and cartilage, osteoporosis
|
|
733.09
|
Other osteoporosis
|
|
733.10–733.16
|
Other disorders of bone and cartilage, pathologic fracture
|
|
733.19
|
Pathologic fracture of other specified site
|
|
733.20–733.22
|
Other disorders of bone and cartilage, cyst of bone
|
|
733.29
|
Other bone cyst
|
|
733.3
|
Hyperostosis of skull
|
|
733.40–733.44
|
Other disorders of bone and cartilage, aseptic necrosis of bone
|
|
733.49
|
Aseptic necrosis of other bone sites
|
|
733.5–733.7
|
Other disorders of bone and cartilage
|
|
733.81–733.82
|
Malunion and non-union of fracture
|
|
733.90–733.92
|
Disorder of bone and cartilage, unspecified
|
|
733.99
|
Other disorders of bone and cartilage, other
|
|
737.0
|
Adolescent postural kyphosis
|
|
737.10–737.12
|
Curvature of spine, kyphosis (acquired)
|
|
737.19
|
Other kyphosis, (acquired) (postural)
|
|
737.20–737.22
|
Curvature of spine, lordosis (acquired)
|
|
737.29
|
Other lordosis, acquired
|
|
737.30–737.34
|
Curvature of spine, kyphoscoliosis and scoliosis
|
|
737.39
|
Other kyphoscoliosis and scoliosis
|
|
737.40–737.43
|
Curvature of spine associated with other conditions
|
|
737.8*–737.9*
|
Curvature of spine
|
|
Note: Use 737.8 or 737.9 to indicate patients with clinically significant symptoms or for pre-operative evaluation.
|
||
738.4
|
Acquired spondylolisthesis
|
|
741.00–741.02
|
Spina bifida, with hydrocephalus
|
|
741.90
|
Spina bifida, unspecified region, without mention of hydrocephalus
|
|
741.92
|
Spina bifida, thoracic region, without mention of hydrocephalus
|
|
742.51
|
Diastematomyelia
|
|
742.53
|
Hydromyelia
|
|
742.59
|
Other specified congenital anomalies of spinal cord
|
|
742.9
|
Unspecified congenital anomaly of brain, spinal cord, and nervous system
|
|
747.82
|
Spinal vessel anomaly
|
|
754.2
|
Congenital musculoskeletal deformities of spine
|
|
756.12
|
Spondylolisthesis, congenital
|
|
756.4
|
Chondrodystrophy
|
|
767.4
|
Injury to spine and spinal cord due to birth trauma
|
|
781.2
|
Abnormality of gait
|
|
781.4
|
Transient paralysis of limb
|
|
782.0
|
Symptom, disturbance of skin sensation
|
|
793.7*
|
Non-specific (abnormal) findings on radiological and other examination of musculoskeletal system
|
|
Note: Use 793.7 to indicate an abnormal bone scan.
|
||
793.91
|
Image test inconclusive due to excess body fat
|
|
793.99
|
Other nonspecific (abnormal) findings on radiological and other examination of body structure
|
|
805.2–805.3
|
Fracture of vertebral column without mention of spinal cord injury
|
|
805.8–805.9
|
Fracture of vertebral column without mention of spinal cord injury
|
|
806.20–806.29
|
Fracture of vertebral column with spinal cord injury, dorsal [thoracic], closed
|
|
806.30–806.39
|
Fracture of vertebral column with spinal cord injury, dorsal [thoracic], open
|
|
806.60–806.62
|
Fracture of vertebral column with spinal cord injury, sacrum and coccyx, closed
|
|
806.69
|
Closed fracture of sacrum and coccyx with other spinal cord injury
|
|
806.70–806.72
|
Fracture of vertebral column with spinal cord injury, sacrum and coccyx, open
|
|
806.79
|
Open fracture of sacrum and coccyx with other spinal cord injury
|
|
806.8–806.9
|
Fracture of vertebral column with spinal cord injury
|
|
839.21
|
Closed dislocation, thoracic vertebra
|
|
839.31
|
Open dislocation, thoracic vertebra
|
|
839.49
|
Closed dislocation, other vertebra, other
|
|
839.59
|
Open dislocation, other vertebra, other
|
|
909.2
|
Late effect of radiation
|
|
926.11
|
Crushing injury of back
|
|
952.10–952.19
|
Spinal cord injury without evidence of spinal bone injury, dorsal [thoracic]
|
|
952.8–952.9
|
Spinal cord injury without evidence of spinal bone injury
|
|
953.1
|
Injury to dorsal nerve root
|
List C
Medicare is establishing the following limited coverage for CPT/HCPCS codes 72131, 72132, 72133, 72148, 72149 and 72158 (CT and MRI of lumbar spine):
Covered for:
003.21
|
Salmonella meningitis
|
013.00–013.06
|
Tuberculous meningitis
|
013.40–013.46
|
Tuberculoma of spinal cord
|
013.50–013.56
|
Tuberculous abscess of spinal cord
|
013.60–013.66
|
Tuberculous encephalitis or myelitis
|
015.00–015.06
|
Tuberculosis of vertebral column
|
045.00–045.03
|
Acute paralytic poliomyelitis specified as bulbar
|
045.10–045.13
|
Acute poliomyelitis with other paralysis
|
045.20–045.23
|
Acute non-paralytic poliomyelitis
|
045.90–045.93
|
Acute poliomyelitis, unspecified
|
091.81
|
Acute syphilitic meningitis (secondary)
|
094.0–094.3
|
Neurosyphilis
|
094.81–094.87
|
Other specified neurosyphilis
|
094.89
|
Other specified neurosyphilis, other
|
094.9
|
Neurosyphilis, unspecified
|
098.82
|
Gonococcal meningitis
|
100.81
|
Leptospiral meningitis (aseptic)
|
112.83
|
Candidal meningitis
|
114.2
|
Coccidioidal meningitis
|
115.01
|
Histoplasma capsulatum meningitis
|
115.11
|
Histoplasma duboisii meningitis
|
130.0
|
Meningoencephalitis due to toxoplasmosis
|
140.0–140.1
|
Malignant neoplasm of lip
|
140.3–140.6
|
Malignant neoplasm of lip
|
140.8–140.9
|
Malignant neoplasm of lip
|
141.0–141.6
|
Malignant neoplasm of tongue
|
141.8–141.9
|
Malignant neoplasm of tongue
|
142.0–142.2
|
Malignant neoplasm of major salivary glands
|
142.8–142.9
|
Malignant neoplasm of major salivary glands
|
143.0–143.1
|
Malignant neoplasm of gum
|
143.8–143.9
|
Malignant neoplasm of gum
|
144.0–144.1
|
Malignant neoplasm of floor of mouth
|
144.8–144.9
|
Malignant neoplasm of floor of mouth
|
145.0–145.6
|
Malignant neoplasm of other and unspecified parts of mouth
|
145.8–145.9
|
Malignant neoplasm of other and unspecified parts of mouth
|
146.0–146.9
|
Malignant neoplasm of oropharynx
|
147.0–147.3
|
Malignant neoplasm of nasopharynx
|
147.8–147.9
|
Malignant neoplasm of nasopharynx
|
148.0–148.3
|
Malignant neoplasm of hypopharynx
|
148.8–148.9
|
Malignant neoplasm of hypopharynx
|
149.0–149.1
|
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
|
149.8–149.9
|
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity, and pharynx
|
150.0–150.5
|
Malignant neoplasm of esophagus
|
150.8–150.9
|
Malignant neoplasm of esophagus
|
151.0–151.6
|
Malignant neoplasm of stomach
|
151.8–151.9
|
Malignant neoplasm of stomach
|
152.0–152.3
|
Malignant neoplasm of small intestine, including duodenum
|
152.8–152.9
|
Malignant neoplasm of small intestine, including duodenum
|
153.0–153.9
|
Malignant neoplasm of colon
|
154.0–154.3
|
Malignant neoplasm of rectum, rectosigmoid junction, and anus
|
154.8
|
Malignant neoplasm of anus unspecified
|
155.0–155.2
|
Malignant neoplasm of liver and intrahepatic bile ducts
|
156.0–156.2
|
Malignant neoplasm of gallbladder and extrahepatic bile ducts
|
156.8–156.9
|
Malignant neoplasm of gallbladder and extrahepatic bile ducts
|
157.0–157.4
|
Malignant neoplasm of pancreas
|
157.8–157.9
|
Malignant neoplasm of pancreas
|
158.0
|
Malignant neoplasm of retroperitoneum
|
158.8
|
Malignant neoplasm of specified parts of peritoneum
|
159.0–159.1
|
Malignant neoplasm of other and ill-defined sites within the digestive organs and peritoneum
|
159.8–159.9
|
Malignant neoplasm of other and ill-defined sites within the digestive organs and peritoneum
|
160.0–160.5
|
Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
|
160.8–160.9
|
Malignant neoplasm of nasal cavities, middle ear, and accessory sinuses
|
161.0–161.3
|
Malignant neoplasm of larynx
|
161.8–161.9
|
Malignant neoplasm of larynx
|
162.0
|
Malignant neoplasm of trachea
|
162.2–162.5
|
Malignant neoplasm of trachea, bronchus, and lung
|
162.8–162.9
|
Malignant neoplasm of trachea, bronchus, and lung
|
163.0–163.1
|
Malignant neoplasm of pleura
|
163.8–163.9
|
Malignant neoplasm of pleura
|
164.0–164.3
|
Malignant neoplasm of thymus, heart, and mediastinum
|
164.8–164.9
|
Malignant neoplasm of thymus, heart, and mediastinum
|
165.0
|
Malignant neoplasm of upper respiratory tract, part unspecified
|
165.8–165.9
|
Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs
|
170.0–170.9
|
Malignant neoplasm of bone and articular cartilage
|
171.0
|
Malignant neoplasm of connective and other soft tissue, head, face and neck
|
171.2–171.9
|
Malignant neoplasm of connective and other soft tissue
|
172.0–172.9
|
Malignant melanoma of skin
|
173.0–173.9
|
Other malignant neoplasm of skin
|
174.0–174.6
|
Malignant neoplasm of female breast
|
174.8–174.9
|
Malignant neoplasm of female breast
|
175.0
|
Malignant neoplasm of male breast, nipple and areola
|
175.9
|
Malignant neoplasm of other and unspecified sites of male breast
|
176.0–176.5
|
Kaposi’s sarcoma
|
176.8–176.9
|
Kaposi’s sarcoma
|
179
|
Malignant neoplasm of uterus, part unspecified
|
180.0–180.1
|
Malignant neoplasm of cervix uteri
|
180.8–180.9
|
Malignant neoplasm of cervix uteri
|
181
|
Malignant neoplasm of placenta
|
182.0–182.1
|
Malignant neoplasm of body of uterus
|
182.8
|
Malignant neoplasm of other specified site of body of uterus
|
183.0
|
Malignant neoplasm of ovary
|
183.2–183.5
|
Malignant neoplasm of ovary and other uterine adnexa
|
183.8–183.9
|
Malignant neoplasm of ovary and other uterine adnexa
|
184.0–184.4
|
Malignant neoplasm of other and unspecified female genital organs
|
184.8–184.9
|
Malignant neoplasm of other and unspecified female genital organs
|
185
|
Malignant neoplasm of prostate
|
186.0
|
Malignant neoplasm of undescended testis
|
186.9
|
Malignant neoplasm of other and unspecified testis
|
187.1–187.9
|
Malignant neoplasm of penis and other male genital organs
|
188.0–188.9
|
Malignant neoplasm of bladder
|
189.0–189.4
|
Malignant neoplasm of kidney and other and unspecified urinary organs
|
189.8–189.9
|
Malignant neoplasm of kidney and other and unspecified urinary organs
|
190.0–190.9
|
Malignant neoplasm of eye
|
192.1–192.3
|
Malignant neoplasm of cerebral meninges, spinal cord, and spinal meninges
|
193
|
Malignant neoplasm of thyroid gland
|
194.6
|
Malignant neoplasm of aortic body and other paraganglia
|
195.0–195.5
|
Malignant neoplasm of other and ill-defined sites
|
195.8
|
Malignant neoplasm of other specified sites
|
196.0–196.3
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
196.5–196.6
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
196.8–196.9
|
Secondary and unspecified malignant neoplasm of lymph nodes
|
197.0–197.8
|
Secondary malignant neoplasm of respiratory and digestive systems
|
198.0*–198.7*
|
Secondary malignant neoplasm of other specified sites
|
198.81*–198.82*
|
Secondary malignant neoplasm of other specified sites
|
198.89*
|
Secondary malignant neoplasm of other specified sites
|
Note: Use 198.XX range of codes to indicate metastases to the spinal column.
|
|
199.0–199.2
|
Malignant neoplasm without specification of site
|
200.00–200.08
|
Reticulosarcoma
|
200.10–200.18
|
Lymphosarcoma
|
200.20–200.28
|
Burkitt’s tumor or lymphoma
|
200.30–200.38
|
Marginal zone lymphoma
|
200.40–200.48
|
Mantle cell lymphoma
|
200.50–200.58
|
Primary central nervous system lymphoma
|
200.60–200.68
|
Anaplastic large cell lymphoma
|
200.70–200.78
|
Large cell lymphoma
|
200.80–200.88
|
Lymphosarcoma and reticulosarcoma, other named variants
|
201.00–201.08
|
Hodgkin’s paragranuloma
|
201.10–201.18
|
Hodgkin’s granuloma
|
201.20–201.28
|
Hodgkin’s sarcoma
|
201.40–201.48
|
Hodgkin’s disease, lymphocytic-histiocytic predominance
|
201.50–201.58
|
Hodgkin’s disease, nodular sclerosis
|
201.60–201.68
|
Hodgkin’s disease, mixed cellularity
|
201.70–201.78
|
Hodgkin’s disease, lymphocytic depletion
|
201.90–201.98
|
Hodgkin’s disease, unspecified
|
202.00–202.08
|
Nodular lymphoma
|
202.10–202.18
|
Mycosis fungoides
|
202.20–202.28
|
Sezary’s disease
|
202.30–202.38
|
Malignant histiocytosis
|
202.40–202.48
|
Leukemic reticuloendotheliosis
|
202.50–202.58
|
Letterer-Siwe disease
|
202.60–202.68
|
Malignant mast cell tumors
|
202.70–202.78
|
Peripheral T cell lymphoma
|
202.80–202.88
|
Other lymphomas
|
202.90–202.98
|
Other and unspecified malignant neoplasms of lymphoid and histocytic tissue
|
203.00–203.02
|
Multiple myeloma
|
203.10–203.12
|
Plasma cell leukemia
|
203.80–203.82
|
Other immunoproliferative neoplasms
|
204.00–204.02
|
Acute lymphoid leukemia
|
204.10–204.12
|
Chronic lymphoid leukemia
|
204.20–204.22
|
Subacute lymphoid leukemia
|
204.80–204.82
|
Other lymphoid leukemia
|
204.90–204.92
|
Unspecified lymphoid leukemia
|
205.00–205.02
|
Acute myeloid leukemia
|
205.10–205.12
|
Chronic myeloid leukemia
|
205.20–205.22
|
Subacute myeloid leukemia
|
205.30–205.32
|
Myeloid sarcoma
|
205.80–205.82
|
Other myeloid leukemia
|
205.90–205.92
|
Unspecified myeloid leukemia
|
206.00–206.02
|
Acute monocytic leukemia
|
206.10–206.12
|
Chronic monocytic leukemia
|
206.20–206.22
|
Subacute monocytic leukemia
|
206.80–206.82
|
Other monocytic leukemia
|
206.90–206.92
|
Unspecified monocytic leukemia
|
207.00–207.02
|
Acute erythremia and erythroleukemia
|
207.10–207.12
|
Chronic erythremia
|
207.20–207.22
|
Megakaryocytic leukemia
|
207.80–207.82
|
Other specified leukemia
|
208.00–208.02
|
Acute leukemia of unspecified cell type
|
208.10–208.12
|
Chronic leukemia of unspecified cell type
|
208.20–208.22
|
Subacute leukemia of unspecified cell type
|
208.80–208.82
|
Other leukemia of unspecified cell type
|
208.90–208.92
|
Unspecified leukemia of unspecified cell type
|
213.2
|
Benign neoplasm of vertebral column, excluding sacrum and coccyx
|
213.6
|
Benign neoplasm of pelvic bones, sacrum, and coccyx
|
213.9
|
Benign neoplasm of bone and articular cartilage, site unspecified
|
215.8–215.9
|
Other benign neoplasm of connective and other soft tissue
|
225.3–225.4
|
Benign neoplasm of brain and other parts of nervous system
|
225.8–225.9
|
Benign neoplasm of brain and other parts of nervous system
|
227.6
|
Benign neoplasm of aortic body and other paraganglia
|
228.00
|
Hemangioma of unspecified site
|
228.09
|
Hemangioma of other sites
|
237.3
|
Neoplasm of uncertain behavior of paraganglia
|
237.5–237.6
|
Neoplasm of uncertain behavior of endocrine glands and nervous system
|
237.70–237.73
|
Neurofibromatosis
|
237.79
|
Other neurofibromatosis
|
237.9
|
Neoplasm of uncertain behavior of other and unspecified parts of nervous system
|
238.0–238.1
|
Neoplasm of uncertain behavior of other and unspecified sites and tissues
|
238.6
|
Neoplasm of uncertain behavior of plasma cells
|
238.72–238.75
|
Neoplasm of uncertain behavior of other lymphatic and hematopoietic tissues
|
239.2
|
Neoplasm of unspecified nature of bone, soft tissue, and skin
|
239.6–239.7
|
Neoplasm of unspecified nature
|
239.89
|
Neoplasms of unspecified nature, other specified sites
|
320.0–320.3
|
Bacterial meningitis
|
320.7
|
Meningitis in other bacterial diseases classified elsewhere
|
320.81–320.82
|
Meningitis due to other specified bacteria
|
320.89
|
Meningitis due to other specified bacteria
|
320.9
|
Meningitis due to unspecified bacterium
|
321.0–321.4
|
Meningitis due to other organisms
|
321.8
|
Meningitis due to other non-bacterial organisms classified elsewhere
|
322.0–322.2
|
Meningitis of unspecified cause
|
322.9
|
Meningitis, unspecified
|
323.01–323.02
|
Encephalitis, myelitis, and encephalomyelitis in viral diseases, classified elsewhere
|
323.1–323.2
|
Encephalitis, myelitis, and encephalomyelitis
|
323.41–323.42
|
Other encephalitis, myelitis, and encephalomyelitis due to infection, classified elsewhere
|
323.52
|
Myelitis following immunization procedures
|
323.61–323.63
|
Postinfectious encephalitis, myelitis, and encephalomyelitis
|
323.71–323.72
|
Toxic encephalitis and encephalomyelitis – Toxic myelitis
|
323.81–323.82
|
Other causes of encephalitis, myelitis, and encephalomyelitis
|
323.9
|
Unspecified cause of encephalitis
|
324.1
|
Intraspinal abscess
|
326*
|
Late effects of intracranial abscess or pyogenic infection
|
Note: Use 326 to indicate late effects of syringomyelitis.
|
|
335.20–335.24
|
Motor neuron disease
|
335.29
|
Other motor neuron diseases
|
336.0–336.3
|
Other diseases of spinal cord
|
336.8*–336.9*
|
Other diseases of spinal cord
|
Note: Use 336.8 or 336.9 to indicate cord compression.
|
|
340
|
Multiple sclerosis
|
341.0–341.1
|
Other demyelinating diseases of central nervous system
|
341.8–341.9
|
Other demyelinating diseases of central nervous system
|
343.0–343.4
|
Infantile cerebral palsy
|
344.00–344.04
|
Other paralytic syndromes
|
344.09
|
Other quadriplegia
|
344.60–344.61
|
Other paralytic syndromes, cauda equina syndrome
|
344.89
|
Other specified paralytic syndrome
|
349.1–349.2
|
Other and unspecified disorders of the nervous system
|
349.31
|
Accidental puncture or laceration of dura during a procedure
|
349.39
|
Other dural tear
|
353.1
|
Lumbosacral plexus lesions
|
353.4
|
Lumbosacral root lesions, not elsewhere classified
|
353.8
|
Other nerve root and plexus disorders
|
355.71
|
Causalgia of lower limb
|
442.89*
|
Aneurysm of other specified site
|
Note: Use 442.89 to indicate aneurysm of spinal artery.
|
|
720.0
|
Ankylosing spondylitis
|
720.81
|
Inflammatory spondylopathies in diseases classified elsewhere
|
721.42
|
Spondylosis with myelopathy, lumbar region
|
721.91
|
Spondylosis of unspecified site with myelopathy
|
722.10
|
Displacement of lumbar intervertebral disc without myelopathy
|
722.2
|
Displacement of intervertebral disc, site unspecified, without myelopathy
|
722.52
|
Degeneration of lumbar or lumbosacral intervertebral disc
|
722.73
|
Intervertebral disc disorder with myelopathy, lumbar region
|
722.83
|
Postlaminectomy syndrome of lumbar region
|
722.93
|
Other and unspecified disc disorder of lumbar region
|
724.00
|
Spinal stenosis, unspecified region
|
724.02–724.03
|
Spinal stenosis, unspecified region
|
724.3–724.4
|
Other and unspecified disorders of back
|
730.08
|
Acute osteomyelitis involving other specified sites
|
730.18
|
Chronic osteomyelitis involving other specified sites
|
732.0
|
Juvenile osteochondrosis of spine
|
733.00–733.03
|
Other disorders of bone and cartilage, osteoporosis
|
733.09
|
Other osteoporosis
|
733.10–733.16
|
Other disorders of bone and cartilage, pathologic fracture
|
733.19
|
Pathologic fracture of other specified site
|
733.20–733.22
|
Other disorders of bone and cartilage, cyst of bone
|
733.29
|
Other bone cyst
|
733.3
|
Hyperostosis of skull
|
733.40–733.44
|
Other disorders of bone and cartilage, aseptic necrosis of bone
|
733.49
|
Aseptic necrosis of other bone sites
|
733.5–733.7
|
Other disorders of bone and cartilage
|
733.81–733.82
|
Malunion and non-union of fracture
|
733.90–733.92
|
Disorder of bone and cartilage, unspecified
|
733.99
|
Other disorders of bone and cartilage, other
|
737.0
|
Adolescent postural kyphosis
|
737.10–737.12
|
Curvature of spine, kyphosis (acquired)
|
737.19
|
Other kyphosis, (acquired) (postural)
|
737.20–737.22
|
Curvature of spine, lordosis (acquired)
|
737.29
|
Other lordosis, acquired
|
737.30–737.34
|
Curvature of spine, kyphoscoliosis and scoliosis
|
737.39
|
Other kyphoscoliosis and scoliosis
|
737.40–737.43
|
Curvature of spine associated with other conditions
|
737.8*–737.9*
|
Curvature of spine
|
Note: Use 737.8 or 737.9 to indicate patients with clinically significant symptoms or for pre-operative evaluation.
|
|
738.4
|
Acquired spondylolisthesis
|
741.00
|
Spina bifida, unspecified region, with hydrocephalus
|
741.03
|
Spina bifida, lumbar region, with hydrocephalus
|
741.90
|
Spina bifida, unspecified region, without mention of hydrocephalus
|
741.93
|
Spina bifida, lumbar region, without mention of hydrocephalus
|
742.51
|
Diastematomyelia
|
742.53
|
Hydromyelia
|
742.59
|
Other specified congenital anomalies of spinal cord
|
742.9
|
Unspecified congenital anomaly of brain, spinal cord, and nervous system
|
747.82
|
Spinal vessel anomaly
|
754.2
|
Congenital musculoskeletal deformities of spine
|
756.11–756.12
|
Anomalies of spine
|
756.17
|
Spina bifida occulta
|
756.4
|
Chondrodystrophy
|
767.4
|
Injury to spine and spinal cord due to birth trauma
|
781.2
|
Abnormality of gait
|
781.4
|
Transient paralysis of limb
|
782.0
|
Symptom, disturbance of skin sensation
|
793.7*
|
Non-specific (abnormal) findings on radiological and other examination of musculoskeletal system
|
Note: Use 793.7 to indicate an abnormal bone scan.
|
|
793.91
|
Image test inconclusive due to excess body fat
|
793.99
|
Other nonspecific (abnormal) findings on radiological and other examination of body structure
|
805.4–805.9
|
Closed fracture of lumbar vertebra without mention of spinal cord injury
|
806.4–806.5
|
Fracture of lumbar spine with spinal cord injury
|
806.60–806.62
|
Fracture of vertebral column with spinal cord injury, sacrum and coccyx, closed
|
806.69
|
Closed fracture of sacrum and coccyx with other spinal cord injury
|
806.70–806.72
|
Fracture of vertebral column with spinal cord injury, sacrum and coccyx, open
|
806.79
|
Open fracture of sacrum and coccyx with other spinal cord injury
|
839.20
|
Closed dislocation, lumbar vertebra
|
839.30
|
Open dislocation, lumbar vertebra
|
839.41–839.42
|
Other multiple and ill-defined dislocations, other vertebra, closed
|
839.49
|
Closed dislocation, other vertebra, other
|
839.51–839.52
|
Other multiple and ill-defined dislocations, other vertebra, open
|
839.59
|
Open dislocation, other vertebra, other
|
909.2
|
Late effect of radiation
|
926.11
|
Crushing injury of back
|
952.2–952.4
|
Spinal cord injury without evidence of spinal bone injury
|
952.8–952.9
|
Spinal cord injury without evidence of spinal bone injury
|
953.2–953.3
|
Injury to nerve roots and spinal plexus
|
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes that Support Medical Necessity” section of this LCD.
Documentation Requirements
Both MRI and CT scans may be necessary in certain circumstances. The medical record must clearly document the reasons for employing both imaging modalities.
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Appendices
N/A
Utilization Guidelines
N/A
Sources of Information and Basis for Decision
J4 (CO, NM, OK, TX) MAC Consolidation
TrailBlazer adopted the TrailBlazer LCD, “Imaging of the Spine: MRI and CT,” for the Jurisdiction 4 (J4) MAC transition.
Full disclosure of the sources of information is found with original contractor LCD.
Other Contractor Local Coverage Determinations
“Imaging of the Spine: MRI and CT,” TrailBlazer LCD, (00400) L17094, (00900) L17100.
“MRI and CT Scans of the Cervical, Thoracic and Lumbar Spine,” Noridian Administrative Services, LLC LCD, (CO) L14474 and L23880.
Start Date of Notice Period
Revision History
Number
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Date
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Explanation
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R4
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01/01/2011
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Per CR 7121 (Annual HCPCS Update), description changed for the GA modifier in the article. Effective date: 01/01/2011.
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R3
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10/18/2010
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Use of LCD and related article made applicable to providers transitioning from WPS to TrailBlazer with addition of Contractor number 04901. Effective date: dates of service on or after 10/18/2010.
Per CR 7006 (Annual ICD-9-CM Diagnosis Coding Update), added diagnosis codes 237.73 and 237.79 to limited coverage List A (72125, 72126, 72127, 72141, 72142 and 72156), List B (72128, 72129, 72130, 72146, 72147 and 72157) and List C (72131, 72132, 72133, 72148, 72149 and 72158). Description changed for diagnosis code 724.02 and added 724.03 to List C. Effective date: 10/01/2010.
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R2
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10/01/2009
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Per CR 6520, Annual ICD-9-CM Diagnosis Coding Update, added new diagnosis code 239.89 (neoplasms of unspecified nature, other specified sites) and corrected punctuation in the code descriptions for diagnosis codes 793.7 and 793.99 in the limited coverage for List A (72125, 72126, 72127, 72141, 72142, 72156), List B (72128, 72129, 72130, 72146, 72147, 72157) and List C (72131, 72132, 72133, 72148, 72149 and 72158). Effective date: 10/01/2009.
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R1
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10/01/2008
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Per CR 6107 (Annual ICD–9–CM Diagnosis Coding Update) added new diagnosis codes 199.2, 203.02, 203.12, 203.82, 204.02, 204.12, 204.22, 204.82, 204.92, 205.02, 205.12, 205.22, 205.32, 205.82, 205.92, 206.02, 206.12, 206.22, 206.82, 206.92, 207.02, 207.12, 207.22, 207.82, 208.02, 208.12, 208.22, 208.82, 208.92, 349.31, 349.39 to limited coverage for HCPCS codes (List A: 72125, 72126, 72127, 72141, 72142, 72156) (List B: 72128, 72129, 72130, 72146, 72147, 72157) (List C: 72131, 72132, 72133, 72148, 72149 and 72158). Effective date: 10/01/2008.
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N/A
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LCD effective in TX Part A and Part B and Part A CO and NM
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N/A
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LCD effective in CO Part B
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N/A
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LCD effective in NM Part B and OK Part A and Part B
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Consolidated LCD posted for notice effective:
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