Molecular diagnostic testing, which includes DNA- or RNA-based analysis, with or without amplification/quantification, 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 such techniques for the former category, in which three basic nucleic acid assay platforms are utilized.
A standardized nucleic acid probe reacts directly with nucleic acids in the test sample. This format is termed a Nucleic Acid Test (NAT). If the test sample contains the organism of interest, then the reaction (e.g., hybridization) of these elements will create a detectable endpoint.
In the second case, test sample nucleic acid is detected following amplification. This format is termed a Nucleic Acid Amplification Test (NAAT). The NAAT format increases diagnostic sensitivity by decreasing the lower limit of detection. Several techniques are available to perform such amplification, but one example is the polymerase chain reaction in which logarithmic copies of baseline nucleic acid material can be replicated via cyclical reactions involving “primer” nucleic acid, enzymes and requisite heating/cooling parameters.
Finally, there may be a need for the above process to quantify, rather than simply detect the presence of, certain microorganisms. Examples include Human Immunodeficiency Virus (HIV), hepatitis C and Cytomegalovirus (CMV) treatment, which can require such quantitative monitoring to determine if therapy is producing the intended reductions in circulating levels of virus.
Furthermore, other techniques (i.e., nucleic acid sequencing) are utilized to assay anti-viral resistance signatures for HIV-1 and hepatitis C. Either genotypic or phenotypic analysis can allow therapy to be directed in response to such observed resistance markers.
There are many different organisms whose clinical presentations can be grouped into several categories or clusters. The table below denotes infectious disease manifestations for those organisms where specific CPT codes exist versus organisms which would require non-specific coding. Other organisms, in addition to those listed below, may also require molecular diagnostic testing.
|
Cluster
|
Organisms With CPT Codes
|
Organisms Without Codes
|
Clinical Features
|
|
Systemic
|
Bartonella henselae; Bartonella quintana; Borrelia burgdorferi;Enterovirus; Herpes virus-6
|
Ehrlichia species; Leishmania species; Parvovirus B19; Babesia species;Herpes virus-7; West Nile virus
|
Endocarditis, fever, peliosis hepatis, hepatitis, rash, cat-scratch disease, oculo-glandular fever, bacillary angiomatosis, encephalitis, lymphadenopathy, meningismus, anorexia, headache, shock, myalgia, arthralgia, Bell’s palsy, meningitis, fatigue, heart block, tick exposure, erythema chronicum migrans, leukopenia, leukocytosis, low platelets
|
|
Respiratory
|
Chlamydia pneumoniae; Mycoplasma pneumoniae; Legionella pneumophila
|
Bordetella pertussis; respiratory syncytial virus; Adenovirus; Parainfluenza virus 1/2/3; Influenza virus A/B;H1N1 virus; Severe Acute Respiratory Syndrome (SARS) -related coronavirus
|
Cough, Shortness of Breath (SOB), fever, chest pain, dyspnea on exertion, leukopenia, leukocytosis, increased Lactate Dehydrogenase (LDH), respiratory failure, pneumonia (including presumed atypical etiologies), pleural effusion, abnormal Liver Function Tests (LFT), hoarseness, “whooping cough,” bronchitis, chronic cough, hemoptysis, abnormal sputum, coma, malaise, fatigue, anorexia, headache, wheezing, respiratory distress, abnormal chest sounds, erythema multiforme, Stevens-Johnson syndrome, cold agglutinin disease, Raynaud’s syndrome, non-specific skin rashes
|
|
Central Nervous System
|
Herpes simplex virus; Cytomegalovirus (CMV); Enterovirus
|
Toxoplasma gondii;Varicella-Zoster Virus (VZV) ; West Nile virus
|
Fever, headache, seizure, photophobia, altered mental status, coma, delirium, abnormal Computed Tomography (CT) of the head, abnormal chemistry, abnormal Complete Blood Count (CBC), genital lesion plus headache, alteration of consciousness, hallucination, meningismus, abnormal spinal fluid, leukopenia, leukocytosis, hepatitis, pneumonia, skin lesions (genital or other), erythema multiforme, Stevens-Johnson syndrome, viremia
|
|
Transplantation/ Immuno-compromised
|
Herpes virus-6; CMV
|
Epstein-Barr virus; VZV; Polyomavirus (JC/BK); HTLV-1;Herpes virus-7
|
Fever, leukopenia, fatigue, abnormal LFT, elevated creatinine, signs and symptoms of rejection, altered mental status, pneumonitis, retinitis, encephalitis, hepatitis, “viral syndrome,” colitis, esophagitis, post-transplant lymphoproliferative disease, hepatosplenomegaly, nephropathy, hemorrhagic cystitis, hematuria, abnormal urine sediment, abnormal CT, altered vision, loss of vision, “floaters,” CNS lymphoma, lymphadenopathy, brain mass
|
|
HIV
|
HIV-1; HIV-2
|
N/A
|
|
|
Hepatitis
|
Hepatitis B, C and G
|
N/A
|
|
|
Mycobacteria
|
M. tuberculosis; M. avium-intracellulare;Mycobacterial species
|
N/A
|
Fever, night sweats, weight loss, fatigue, SOB, cough, abnormal chest X-ray/CT, including miliary pattern, abnormal LFT, cavitary lesions, anorexia, hemoptysis, myalgias, hematuria, vaginal bleeding, abdominal pain, obstruction, neck mass, lymphadenopathy, abnormal sputum, abdominal mass, ascites, leukocytosis, leukopenia
|
|
Cervicitis/ Urethritis/ Vaginitis
|
Chlamydia trachomatis; Neisseria gonorrhoeae; Gardnerella vaginalis; Trichomonas vaginalis;Candida species
|
N/A
|
Genital ulcers, genital lesions, urethritis, vaginitis, cervicitis, Pelvic Inflammatory Disease (PID), Reiter’s disease, pelvic/peritoneal adhesions (Fitzhugh-Curtis syndrome), infertility of tubal origin,abdominal pain, abdominal tenderness, vaginal discharge, dysuria, salpingitis, epididymitis, prostatitis, proctitis, pharyngitis, orchitis, genital discharge, rash, tenosynovitis, arthritis, arthralgias, bacteremia, fever, quadrant pain, abnormal LFT, abnormal urine, leukocytosis, leukopenia, lymphadenopathy and lymphadenitis, acute/chronic conjunctivitis
|
|
Abnormal Pap Smear
|
Papillomavirus
|
N/A
|
Atypical Squamous Cell Changes of Undetermined Significance (ASCUS), atypical glandular cell changes of undetermined significance, Low-Grade Squamous Intraepithelial Dysplasia (LGSIL)
|
|
Possible Group A Streptococcal Infection
|
Streptococcus, Group A
|
N/A
|
Sore throat, acute pharyngitis, acute nasopharyngitis, fever, headache, vomiting, non-specific abdominal pain, leukocytosis, earache, rheumatic fever, endocarditis, cellulitis, tonsillitis, myositis, toxic shock, myonecrosis, acute glomerulonephritis, serum sickness
|
|
Mucocutaneous
|
Staphylococcus aureus;Methicillin-resistantStaphylococcus aureus;Streptococcus, Group B; Vancomycin-resistant enterococcus
|
N/A
|
Evaluating anatomic sites for carriage of pathogens
|
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
- Safe and effective.
- Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
- Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
- Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
- Furnished in a setting appropriate to the patient’s medical needs and condition.
- Ordered and furnished by qualified personnel.
- One that meets, but does not exceed, the patient’s medical need.
- At least as beneficial as an existing and available medically appropriate alternative.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
12X, 13X, 14X, 18X, 21X, 22X, 23X, 71X, 72X, 73X, 75X, 77X, 83X, 85X
Bill Type Note: Code 73X end-dated for Medicare use March 31, 2010; code 77X effective for dates of service on or after April 1, 2010.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
030X, 031X
CPT/HCPCS Codes
Note: |
Providers are reminded to refer to the long descriptors of the CPT Codes in their CPT book. The AMA and CMS require the use of short CPT descriptors in policies published on the Web.
|
|
87260©
|
Adenovirus, immunofluorescent technique
|
|
87280©
|
Respiratory syncytial virus, immunofluorescent technique
|
|
87471©
|
Bartonella, amp probe
|
|
87476©
|
Lyme dis, amp probe
|
|
87480©
|
Candida, dir probe
|
|
87486©
|
Chylmd pneum, amp probe
|
|
87490©
|
Chylmd trach, dir probe
|
|
87491©
|
Chylmd trach, amp probe
|
|
87496©
|
Cytomeg, amp probe
|
|
87497©
|
Cytomeg, quant
|
|
87498©
|
Enterovirus, dna, amp probe
|
|
87500©
|
Vanomycin, dna, amp probe
|
|
87501©
|
Influenza dna amp prob 1+
|
|
87502©
|
Influenza dna amp probe
|
|
87503©
|
Influenza dna amp prob addl
|
|
87510©
|
Gardner vag, dir probe
|
|
87516©
|
Hepatitis b, amp probe
|
|
87517©
|
Hepatitis b, quant
|
|
87521©
|
Hepatitis c, amp probe
|
|
87522©
|
Hepatitis c, quant
|
|
87526©
|
Hepatitis g, amp probe
|
|
87529©
|
Hsv, amp probe
|
|
87532©
|
Hhv-6, amp probe
|
|
87534©
|
Hiv-1, dir probe
|
|
87535©
|
Hiv-1, amp probe
|
|
87536©
|
Hiv-1, quant
|
|
87537©
|
Hiv-2, dir probe
|
|
87538©
|
Hiv-2, amp probe
|
|
87539©
|
Hiv-2, quant
|
|
87541©
|
Legion pneumo, amp probe
|
|
87551©
|
Mycobacteria, amp probe
|
|
87556©
|
M.tuberculo, amp probe
|
|
87561©
|
M.avium-intra, amp probe
|
|
87581©
|
M.pneumon, amp probe
|
|
87590©
|
N.gonorrhoeae, dir probe
|
|
87591©
|
N.gonorrhoeae, amp probe
|
|
87621©
|
Hpv, amp probe
|
|
87640©
|
Staph a, dna, amp probe
|
|
87641©
|
Mr-staph, dna, amp probe
|
|
87650©
|
Strep a, dir probe
|
|
87653©
|
Strep b, dna, amp probe
|
|
87660©
|
Trichomonas vagin, dir probe
|
|
87797©
|
Detect agent nos, dir probe
|
|
87798©
|
Detect agent nos, amp probe
|
|
87799©
|
Detect agent nos, quant
|
|
87901©
|
Genotype, hiv reverse t
|
|
87902©
|
Genotype, hepatitis c
|
|
87903©
|
Phenotype, hiv w/culture
|
|
87904©
|
Phenotype, hiv w/clt add
|
|
87906©
|
Genotype dna hiv reverse t
|
ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 87471, 87476, 87480, 87486, 87490, 87491, 87496, 87497, 87498, 87500, 87510, 87516, 87517, 87521, 87522, 87526, 87529, 87532, 87534, 87535, 87536, 87537, 87538, 87539, 87541, 87551, 87556, 87561, 87581, 87590, 87591, 87621, 87640, 87641, 87650, 87653, 87660, 87797, 87798, 87799, 87901, 87902, 87903 and 87904:
List A
Medicare is establishing the following limited coverage for Bartonella henselae and Bartonella quintana (87471),Borrelia burgdorferi (87476), enterovirus (87498), herpes virus-6 (87532), Parvovirus B19 (87799) and (87798) for the following organisms – Ehrlichia species, herpes virus-7, West Nile virus, Leishmania species, Parvovirus B19 andBabesia species:
Covered for:
|
040.89
|
Other specified bacterial diseases, other
|
|
058.10–058.12
|
Roseola infantum
|
|
058.81–058.82
|
Human herpesvirus infection
|
|
058.89
|
Other human herpesvirus infection
|
|
078.3
|
Cat-scratch disease
|
|
079.83
|
Parvovirus B19
|
|
087.0–087.1
|
Relapsing fever
|
|
087.9
|
Relapsing fever, unspecified
|
|
088.0
|
Bartonellosis
|
|
088.81
|
Lyme Disease
|
|
287.41
|
Posttransfusion purpura
|
|
287.49
|
Other secondary thrombocytopenia
|
|
287.5
|
Thrombocytopenia, unspecified
|
|
288.00–288.04
|
Neutropenia
|
|
288.09
|
Other neutropenia
|
|
288.66
|
Bandemia
|
|
288.8
|
Other specified disease of white blood cells
|
|
320.9
|
Meningitis due to unspecified bacterium
|
|
322.9
|
Meningitis, unspecified
|
|
323.01–323.02
|
Encephalitis, myelitis, and encephalomyelitis in viral diseases, classified elsewhere
|
|
323.41–323.42
|
Other encephalitis, myelitis, and encephalomyelitis due to infection, classified elsewhere
|
|
323.51–323.52
|
Encephalitis, myelitis, and encephalomyelitis following immunization procedures
|
|
323.61–323.63
|
Postinfectious encephalitis, myelitis, and encephalomyelitis
|
|
323.81–323.82
|
Other causes of encephalitis, myelitis, and encephalomyelitis
|
|
323.9
|
Unspecified causes of encephalitis, myelitis, and encephalomyelitis
|
|
351.0
|
Bell’s palsy
|
|
421.0–421.1
|
Acute and subacute endocarditis
|
|
421.9
|
Acute endocarditis, unspecified
|
|
424.0–424.3
|
Other diseases of endocardium
|
|
424.90–424.91
|
Endocarditis, valve unspecified
|
|
424.99
|
Other endocarditis, valve unspecified
|
|
426.0
|
Atrioventricular block, complete
|
|
426.10–426.13
|
Atrioventricular block, other and unspecified
|
|
426.2–426.4
|
Conduction disorders
|
|
426.50–426.54
|
Bundle branch block, other and unspecified
|
|
426.6–426.7
|
Conduction disorders
|
|
426.81–426.82
|
Other specified conduction disorders
|
|
426.89
|
Other specified conduction disorders
|
|
426.9
|
Conduction disorder, unspecified
|
|
573.9
|
Unspecified disorder of liver
|
|
719.40–719.49
|
Pain in joint
|
|
729.1
|
Myalgia and myositis, unspecified
|
|
780.32
|
Complex febrile convulsions
|
|
780.60–780.61
|
Fever
|
|
780.79
|
Other malaise and fatigue
|
|
781.6
|
Meningismus
|
|
782.1
|
Symptom, rash and other non-specific skin eruption
|
|
783.0
|
Symptoms, anorexia
|
|
784.0
|
Headache
|
|
785.50
|
Shock, unspecified
|
|
785.6
|
Enlargement of lymph nodes
|
|
999.31
|
Infection due to central venous catheter
|
|
999.39
|
Infection following other infusion, injection, transfusion, or vaccination
|
List B
Medicare is establishing the following limited coverage for adenovirus (87260), respiratory syncytial virus(87280),Chlamydia pneumoniae (87486), influenza virus A/B (87501, 87502 and 87503), Legionella pneumophila(87541), Mycoplasma pneumoniae (87581) and (87798) for the following organisms – Bordetella pertussis,parainfluenza virus 1/2/3, SARS-related coronavirus and H1N1 virus:
Covered for:
|
283.0
|
Autoimmune hemolytic anemias
|
|
288.00–288.04
|
Neutropenia
|
|
288.09
|
Other neutropenia
|
|
288.66
|
Bandemia
|
|
288.8
|
Other specified disease of white blood cells
|
|
466.0
|
Acute bronchitis
|
|
482.84
|
Pneumonia due to Legionnaires’ disease
|
|
482.9
|
Bacterial pneumonia, unspecified
|
|
483.0–483.1
|
Pneumonia due to other specified organism
|
|
486
|
Pneumonia, organism unspecified
|
|
488.01
|
Influenza due to identified avian influenza virus with pneumonia
|
|
488.02
|
Influenza due to identified avian influenza virus with other respiratory manifestations
|
|
488.09
|
Influenza due to identified avian influenza virus with other manifestations
|
|
488.11
|
Influenza due to identified novel H1N1 influenza virus with pneumonia
|
|
488.12
|
Influenza due to identified novel H1N1 influenza virus with other respiratory manifestations
|
|
488.19
|
Influenza due to identified novel H1N1 influenza virus with other manifestations
|
|
490
|
Bronchitis, not specified as acute or chronic
|
|
511.89
|
Other specified forms of effusion, except tuberculous
|
|
511.9
|
Unspecified pleural effusion
|
|
518.81
|
Acute respiratory failure
|
|
518.83–518.84
|
Other diseases of lung
|
|
695.10–695.15
|
Erythema multiforme
|
|
695.19
|
Other erythema multiforme
|
|
780.01
|
Coma
|
|
780.79
|
Other malaise and fatigue
|
|
782.1
|
Symptom, rash and other non-specific skin eruption
|
|
783.0
|
Symptoms, anorexia
|
|
784.0
|
Headache
|
|
784.49
|
Other voice and resonance disorders
|
|
786.05
|
Shortness of breath
|
|
786.07
|
Wheezing
|
|
786.09
|
Other dyspnea and respiratory abnormality
|
|
786.2
|
Cough
|
|
786.39
|
Other hemoptysis
|
|
786.50–786.52
|
Chest pain
|
|
786.59
|
Other chest pain
|
|
790.4–790.5
|
Abnormal glucose
|
List C
Medicare is establishing the following limited coverage for cytomegalovirus (87496), enterovirus (87498), herpes simplex virus (87529) and (87798) for the following organisms – toxoplasma gondii, West Nile virus and Varicella-zoster virus:
Covered for:
|
054.3
|
Herpetic meningoencephalitis
|
|
054.72
|
Herpes simplex meningitis
|
|
054.74
|
Herpes simplex myelitis
|
|
058.21
|
Human herpesvirus 6 encephalitis
|
|
058.29
|
Other human herpesvirus encephalitis
|
|
288.00–288.04
|
Neutropenia
|
|
288.09
|
Other neutropenia
|
|
288.66
|
Bandemia
|
|
288.8
|
Other specified disease of white blood cells
|
|
293.0–293.1
|
Transient mental disorders due to conditions classified elsewhere
|
|
345.90–345.91
|
Epilepsy, unspecified
|
|
368.13
|
Visual discomfort
|
|
486
|
Pneumonia, organism unspecified
|
|
573.9
|
Unspecified disorder of liver
|
|
608.89
|
Other specified disorders of male genital organs, other
|
|
629.89
|
Other specified disorders of female genital organs
|
|
695.10–695.15
|
Erythema multiforme
|
|
695.19
|
Other erythema multiforme
|
|
709.9
|
Unspecified disorder of skin and subcutaneous tissue
|
|
780.01–780.03
|
Alternation of consciousness
|
|
780.09
|
Other alteration of consciousness
|
|
780.1
|
Hallucinations
|
|
780.32
|
Complex febrile convulsions
|
|
780.60–780.61
|
Fever
|
|
781.6
|
Meningismus
|
|
789.00–789.07
|
Abdominal pain
|
|
789.09
|
Abdominal pain, other specified site
|
|
790.8
|
Viremia, unspecified
|
|
792.0
|
Non-specific abnormal findings in cerebrospinal fluid
|
List D
Medicare is establishing the following limited coverage for Cytomegalovirus (87496, 87497), Herpes virus-6 (87532),(87798) for the following organisms –, Herpes virus-7, Epstein-Barr virus, Varicella-zoster virus, Polyomavirus [JC/BK] and (87799) for the following organisms – Epstein-Barr virus HTLV-1 and Polyomavirus [JC/BK]:
Covered for:
|
009.1
|
Colitis, enteritis, and gastroenteritis of presumed infectious origin
|
|
058.81–058.82
|
Human herpesvirus infection
|
|
058.89
|
Other human herpesvirus infection
|
|
078.5
|
Cytomegaloviral disease
|
|
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
|
Peripheral T cell lymphoma
|
|
200.80–200.88
|
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
|
Lymphocytic-histiocytic predominance
|
|
201.50–201.58
|
Nodular sclerosis
|
|
201.60–201.68
|
Mixed cellularity
|
|
201.70–201.78
|
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
|
Sézary’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 histiocytic tissue
|
|
238.72–238.75
|
Neoplasm of uncertain behavior of other lymphatic and hematopoietic tissues
|
|
238.77
|
Post-transplant lymphoproliferative disorder (PTLD)
|
|
288.00–288.04
|
Neutropenia
|
|
288.09
|
Other neutropenia
|
|
288.66
|
Bandemia
|
|
288.8
|
Other specified disease of white blood cells
|
|
323.01–323.02
|
Encephalitis, myelitis, and encephalomyelitis in viral diseases, classified elsewhere
|
|
323.41–323.42
|
Other encephalitis, myelitis, and encephalomyelitis due to infection, classified elsewhere
|
|
323.51–323.52
|
Encephalitis, myelitis, and encephalomyelitis following immunization procedures
|
|
323.61–323.63
|
Postinfectious encephalitis, myelitis, and encephalomyelitis
|
|
323.81–323.82
|
Other causes of encephalitis, myelitis, and encephalomyelitis
|
|
323.9
|
Unspecified causes of encephalitis, myelitis, and encephalomyelitis
|
|
363.00–363.01
|
Focal chorioretinitis and focal retinochoroiditis
|
|
363.03–363.08
|
Focal chorioretinitis and focal retinochoroiditis
|
|
363.10–363.15
|
Disseminated chorioretinitis and disseminated retinochoroiditis
|
|
368.40–368.47
|
Visual field defects
|
|
368.8–368.9
|
Visual disturbances
|
|
480.8
|
Pneumonia due to other virus not elsewhere classified
|
|
484.1
|
Pneumonia in cytomegalic inclusion disease
|
|
530.10–530.12
|
Esophagitis
|
|
530.19
|
Other esophagitis
|
|
573.9
|
Unspecified disorder of liver
|
|
583.9
|
Nephritis and nephropathy, not specified as acute or chronic, with unspecified pathological lesion in kidney
|
|
586
|
Renal failure, unspecified
|
|
595.9
|
Cystitis, unspecified
|
|
599.70–599.72
|
Hematuria
|
|
771.1
|
Congenital cytomegalovirus infection
|
|
780.01–780.03
|
Alteration of consciousness
|
|
780.09
|
Other alteration of consciousness
|
|
780.32
|
Complex febrile convulsions
|
|
780.60–780.61
|
Fever
|
|
780.79
|
Other malaise and fatigue
|
|
784.2
|
Swelling, mass, or lump in head and neck
|
|
785.6
|
Enlargement of lymph nodes
|
|
789.1–789.2
|
Other symptoms involving abdomen and pelvis
|
|
790.4
|
Non-specific elevation of levels of transaminase or lactic acid dehydrogenase (LDH)
|
|
790.5
|
Other non-specific abnormal serum enzyme levels
|
|
791.0–791.7
|
Nonspecific findings on examination of urine
|
|
791.9
|
Other non-specific findings on examination of urine
|
|
996.80–996.87
|
Complications of unspecified transplanted organ
|
|
996.89
|
Complications of other specified transplanted organ
|
|
V42.0
|
Organ or tissue replaced by transplant, kidney
|
|
V42.6
|
Organ or tissue replaced by transplant, lung
|
|
V42.81
|
Organ or tissue replaced by transplant, bone marrow
|
|
V42.82
|
Peripheral stem cells replaced by transplant
|
List E
Medicare is establishing the following limited coverage for HIV diagnosis and prognosis, including monitoring (87534, 87535, 87536, 87537, 87538 and 87539):
Covered for:
Documentation in the Federal Register (Federal Register Final Rules (11/23/01)) includes the initial list(s) of ICD-9-CM Diagnosis Codes. Documentation in the NCD Coding Manual Releases (posted by date) includes updated list(s) of ICD-9-CM Diagnosis Codes. To ensure appropriate coding, providers must review ALL the documents.
List F
Medicare is establishing the following limited coverage for HIV genotyping and phenotyping (87901, 87903, 87904and 87906):
Covered for:
|
042
|
Human Immunodeficiency Virus (HIV) Disease
|
|
079.53
|
Human Immunodeficiency Virus Type 2 [Hiv-2]
|
|
647.60–647.64
|
Other Viral Diseases Of Mother Complicating Pregnancy Childbirth Or The Puerperium
|
|
795.71
|
Nonspecific Serologic Evidence Of Human Immunodeficiency Virus (Hiv)
|
|
V08
|
Asymptomatic Human Immunodeficiency Virus (Hiv) Infection Status
|
List G
Medicare is establishing the following limited coverage for hepatitis B, C and G testing (87516, 87517, 87521, 87522 and 87526):
Covered for:
|
070.20–070.23
|
Viral hepatitis b with hepatic coma
|
|
070.30–070.33
|
Viral hepatitis b without mention of hepatic coma
|
|
070.41
|
Acute hepatitis c with hepatic coma
|
|
070.44
|
Chronic hepatitis c with hepatic coma
|
|
070.49
|
Other specified viral hepatitis with hepatic coma
|
|
070.51
|
Acute hepatitis c without hepatic coma
|
|
070.54
|
Chronic hepatitis c without hepatic coma
|
|
070.59
|
Other specified viral hepatitis without hepatic coma
|
|
070.6
|
Unspecified viral hepatitis with hepatic coma
|
|
070.70–070.71
|
Unspecified viral hepatitis C
|
|
070.9
|
Unspecified viral hepatitis without hepatic coma
|
|
456.0–456.1
|
Varicose veins of other sites, esophageal varices
|
|
456.20–456.21
|
Esophageal varices in diseases classified elsewhere
|
|
570
|
Acute and subacute necrosis of liver
|
|
571.5
|
Cirrhosis of liver without alcohol
|
|
572.0–572.4
|
Liver abscess and sequelae of chronic liver disease
|
|
572.8
|
Other sequelae of chronic liver disease
|
|
573.3
|
Hepatitis unspecified
|
|
780.31–780.32
|
Febrile convulsions
|
|
780.71
|
Chronic fatigue syndrome
|
|
780.79
|
Other malaise and fatigue
|
|
782.4
|
Jaundice unspecified not of newborn
|
|
783.0–783.1
|
Symptoms concerning nutrition, metabolism and development
|
|
783.21–783.22
|
Abnormal loss of weight and underweight
|
|
783.3
|
Feeding difficulties and mismanagement
|
|
783.40–783.43
|
Lack of expected normal physiological development in childhood
|
|
783.5–783.6
|
Symptoms concerning nutrition, metabolism and development
|
|
784.69
|
Other symbolic dysfunction
|
|
787.01–787.03
|
Nausea and vomiting
|
|
789.00–789.07
|
Other symptoms involving abdomen and pelvis
|
|
789.09
|
Other symptoms involving abdomen and pelvis, other specified site
|
|
789.1
|
Hepatomegaly
|
|
789.61
|
Abdominal tenderness right upper quadrant
|
|
794.8
|
Nonspecific abnormal results of function study of liver
|
|
996.82
|
Complications of transplanted liver
|
|
999.31
|
Infection due to central venous catheter
|
|
999.39
|
Infection following other infusion, injection, transfusion, or vaccination
|
|
V72.85
|
Other specified examination
|
List H
Medicare is establishing the following limited coverage for hepatitis C genotyping (87902):
Covered for:
|
070.41
|
Acute hepatitis C with hepatic coma
|
|
070.44
|
Chronic hepatitis C with hepatic coma
|
|
070.51
|
Acute hepatitis C without mention of hepatic coma
|
|
070.54
|
Chronic hepatitis C without mention of hepatic coma
|
|
070.70–070.71
|
Unspecified viral hepatitis C
|
|
288.00–288.04
|
Neutropenia
|
|
288.09
|
Other neutropenia
|
|
288.66
|
Bandemia
|
|
288.8
|
Other specified disease of white blood cells
|
|
571.41
|
Chronic persistent hepatitis
|
List I
Medicare is establishing the following limited coverage for mycobacterium tuberculosis (87556), mycobacterium avium-intracellulare (87561) and other mycobacteria species (87551):
Covered for:
|
010.00–010.06
|
Primary tuberculous complex
|
|
010.10–010.16
|
Tuberculous pleurisy in primary progressive tuberculosis
|
|
010.80–010.86
|
Other primary progressive tuberculosis
|
|
010.90–010.96
|
Primary tuberculous infection, unspecified
|
|
011.00–011.06
|
Tuberculosis of lung, infiltrative
|
|
011.10–011.16
|
Tuberculosis of lung, nodular
|
|
011.20–011.26
|
Tuberculosis of lung with cavitation
|
|
011.30–011.36
|
Tuberculosis of bronchus
|
|
011.40–011.46
|
Tuberculous fibrosis of lung
|
|
011.50–011.56
|
Tuberculous bronchiectasis
|
|
011.60–011.66
|
Tuberculous pneumonia [any form]
|
|
011.70–011.76
|
Tuberculous pneumothorax
|
|
011.80–011.86
|
Other specified pulmonary tuberculosis
|
|
011.90–011.96
|
Pulmonary tuberculosis, unspecified
|
|
012.00–012.06
|
Tuberculous pleurisy
|
|
012.10–012.16
|
Tuberculosis of intrathoracic lymph nodes
|
|
012.20–012.26
|
Isolated tracheal or bronchial tuberculosis
|
|
012.30–012.36
|
Tuberculous laryngitis
|
|
012.80–012.86
|
Other specified respiratory tuberculosis
|
|
013.00–013.06
|
Tuberculous meningitis
|
|
013.10–013.16
|
Tuberculoma of meninges
|
|
013.20–013.26
|
Tuberculoma of brain
|
|
013.30–013.36
|
Tuberculous abscess of brain
|
|
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
|
|
013.80–013.86
|
Other specified tuberculosis of central nervous system
|
|
013.90–013.96
|
Unspecified tuberculosis of central nervous system
|
|
014.00–014.06
|
Tuberculous peritonitis
|
|
014.80–014.86
|
Other Tuberculosis of intestines, peritoneum, and mesenteric glands
|
|
015.00–015.06
|
Vertebral column
|
|
015.10–015.16
|
Tuberculosis of hip
|
|
015.20–015.26
|
Tuberculosis of knee
|
|
015.50–015.56
|
Tuberculosis of limb bones
|
|
015.60–015.66
|
Tuberculosis of mastoid
|
|
015.70–015.76
|
Tuberculosis of other specified bone
|
|
015.80–015.86
|
Tuberculosis of other specified joint
|
|
015.90–015.96
|
Tuberculosis of unspecified bones and joints
|
|
016.00–016.06
|
Tuberculosis of kidney
|
|
016.10–016.16
|
Tuberculosis of bladder
|
|
016.20–016.26
|
Tuberculosis of ureter
|
|
016.30–016.36
|
Tuberculosis of other urinary organs
|
|
016.40–016.46
|
Tuberculosis of epididymis
|
|
016.50–016.56
|
Tuberculosis of other male genital organs
|
|
016.60–016.66
|
Tuberculous oophoritis and salpingitis
|
|
016.70–016.76
|
Tuberculosis of other female genital organs
|
|
016.90–016.96
|
Unspecified genitourinary tuberculosis
|
|
017.00–017.06
|
Tuberculosis of skin and subcutaneous cellular tissue
|
|
017.10–017.16
|
Erythema nodosum with hypersensitivity reaction in tuberculosis
|
|
017.20–017.26
|
Tuberculosis of peripheral lymph nodes
|
|
017.30–017.36
|
Tuberculosis of eye
|
|
017.40–017.46
|
Tuberculosis of ear
|
|
017.50–017.56
|
Tuberculosis of thyroid gland
|
|
017.60–017.66
|
Tuberculosis of adrenal glands
|
|
017.70–017.76
|
Tuberculosis of spleen
|
|
017.80–017.86
|
Tuberculosis of esophagus
|
|
017.90–017.96
|
Tuberculosis of other specified organs
|
|
018.00–018.06
|
Acute miliary tuberculosis
|
|
018.80–018.86
|
Other specified miliary tuberculosis
|
|
018.90–018.96
|
Unspecified miliary tuberculosis, unspecified
|
|
031.0–031.2
|
Pulmonary diseases due to other mycobacteria
|
|
031.8–031.9
|
Pulmonary diseases due to other mycobacteria
|
|
288.00–288.04
|
Neutropenia
|
|
288.09
|
Other neutropenia
|
|
288.66
|
Bandemia
|
|
288.8
|
Other specified disease of white blood cells
|
|
560.9
|
Unspecified intestinal obstruction
|
|
599.70–599.72
|
Hematuria
|
|
626.8–626.9
|
Disorders of menstruation and other abnormal bleeding from female genital tract
|
|
729.1
|
Myalgia and myositis, unspecified
|
|
780.32
|
Complex febrile convulsions
|
|
780.60–780.61
|
Fever
|
|
780.79
|
Other malaise and fatigue
|
|
780.8
|
Hyperhidrosis
|
|
783.0
|
Symptoms, anorexia
|
|
783.21
|
Symptoms, abnormal loss of weight
|
|
784.2
|
Swelling, mass, or lump in head and neck
|
|
785.6
|
Enlargement of lymph nodes
|
|
786.02
|
Orthopnea
|
|
786.05
|
Shortness of breath
|
|
786.39
|
Other hemoptysis
|
|
789.00–789.07
|
Abdominal pain
|
|
789.09
|
Abdominal pain, other specified site
|
|
789.1–789.2
|
Other symptoms involving abdomen and pelvis
|
|
789.30–789.37
|
Abdominal or pelvic swelling, mass, or lump
|
|
789.39
|
Abdominal or pelvic swelling, mass, or lump, other specified site
|
|
789.51
|
Malignant ascites
|
|
789.59
|
Other ascites
|
List J
Medicare is establishing the following limited coverage for Chlamydia trachomatis (87490, 87491), Neisseria gonorrhoeae (87590, 87591), Candida species (87480), Gardnerella vaginalis (87510) and Trichomonas vaginalis(87660):
Covered for:
|
076.0–076.1
|
Trachoma
|
|
076.9
|
Trachoma, unspecified
|
|
077.0
|
Inclusion conjunctivitis
|
|
077.98–077.99
|
Unspecified diseases of conjunctiva due to viruses and Chlamydiae
|
|
098.0
|
Gonococcal infection (acute) of lower genitourinary tract
|
|
098.10–098.17
|
Acute of upper genitourinary tract
|
|
098.19
|
Other gonococcal infection (acute) of upper genitourinary tract
|
|
098.2
|
Gonococcal infection, chronic, of lower genitourinary tract
|
|
098.30–098.37
|
Chronic, of upper genitourinary tract
|
|
098.39
|
Other chronic gonococcal infection of upper genitourinary tract
|
|
098.40–098.43
|
Gonococcal infection of eye
|
|
098.49
|
Other gonococcal infection of eye
|
|
098.50–098.53
|
Gonococcal infection of joint
|
|
098.59
|
Other gonococcal infection of joint
|
|
098.6–098.7
|
Gonococcal infections
|
|
098.81–098.86
|
Gonococcal infection of other specified sites
|
|
098.89
|
Gonococcal infection of other specified sites, other
|
|
099.1
|
Lymphogranuloma venereum
|
|
099.3
|
Reiter’s disease
|
|
099.41
|
Veneral urethritis due to Chlamydia trachomatis
|
|
099.50–099.56
|
Other venereal diseases due to Chlamydia trachomatis
|
|
099.59
|
Chlamydia trachomatis infection of other specified site
|
|
112.1–112.2
|
Candidiasis
|
|
131.00–131.03
|
Urogenital trichomoniasis
|
|
131.09
|
Other urogenital trichomoniasis
|
|
131.8–131.9
|
Trichomoniasis
|
|
288.00–288.04
|
Neutropenia
|
|
288.09
|
Other neutropenia
|
|
288.66
|
Bandemia
|
|
288.8
|
Other specified disease of white blood cells
|
|
289.1
|
Chronic lymphadenitis
|
|
289.53
|
Neutropenic splenomegaly
|
|
289.83
|
Myelofibrosis
|
|
372.00
|
Acute conjunctivitis, unspecified
|
|
372.02–372.03
|
Acute conjunctivitis
|
|
372.10–372.12
|
Chronic conjunctivitis
|
|
595.4
|
Cystitis in diseases classified elsewhere
|
|
597.80–597.81
|
Other urethritis
|
|
601.0
|
Acute prostatitis
|
|
601.8–601.9
|
Inflammatory diseases of prostate
|
|
604.0
|
Orchitis, epididymitis, and epididymo-orchitis, with abscess
|
|
604.90–604.91
|
Other orchitis, epididymitis, and epididymitis- orchitis, without mention of abscess
|
|
608.89
|
Other specified disorders of male genital organs, other
|
|
614.0
|
Acute salpingitis and oophoritis
|
|
614.2–614.4
|
Inflammatory disease of ovary, fallopian tube, pelvic cellular tissue, and peritoneum
|
|
614.6
|
Pelvic peritoneal adhesions, female
|
|
614.8–614.9
|
Inflammatory disease of ovary, fallopian tube, pelvic cellular tissue, and peritoneum
|
|
616.0
|
Cervicitis and endocervicitis
|
|
616.10–616.11
|
Vaginitis and vulvovaginitis
|
|
616.81
|
Mucositis (ulcerative) of cervix, vagina, and vulva
|
|
616.89
|
Other inflammatory disease of cervix, vagina and vulva
|
|
616.9
|
Unspecified inflammatory diseases of cervix, vagina, and vulva
|
|
628.2
|
Infertility, female, of tubal origin
|
|
629.89
|
Other specified disorders of female genital organs
|
|
683
|
Acute lymphadenitis
|
|
711.90–711.99
|
Unspecified infective arthritis
|
|
716.50–716.59
|
Unspecified polyarthropathy or polyarthritis
|
|
716.60–716.68
|
Unspecified monoarthritis
|
|
716.90–716.99
|
Arthropathy, unspecified
|
|
719.40–719.49
|
Pain in joint
|
|
727.00
|
Synovitis and tenosynovitis, unspecified
|
|
727.05–727.06
|
Synovitis and tenosynovitis, unspecified
|
|
727.09
|
Other synovitis and tenosynovitis
|
|
771.6
|
Neonatal conjunctivitis and dacryocystitis
|
|
780.60–780.61
|
Fever
|
|
782.1
|
Symptom, rash and other non-specific skin eruption
|
|
785.6
|
Enlargement of lymph nodes
|
|
788.1
|
Dysuria
|
|
788.64–788.65
|
Other abnormality of urination
|
|
788.7
|
Urethral discharge
|
|
789.00–789.07
|
Abdominal pain
|
|
789.09
|
Abdominal pain, other specified site
|
|
789.1–789.2
|
Other symptoms involving abdominal and pelvic
|
|
789.30–789.37
|
Abdominal or pelvic swelling, mass, or lump
|
|
789.39
|
Abdominal or pelvic swelling, mass, or lump, other specified site
|
|
789.40–789.47
|
Abdominal rigidity
|
|
789.49
|
Abdominal rigidity, other specified site
|
|
789.51
|
Malignant ascites
|
|
789.59
|
Other ascites
|
|
789.60–789.67
|
Abdominal tenderness
|
|
789.69
|
Abdominal tenderness, other specified site
|
|
789.9
|
Other symptoms involving abdomen and pelvis
|
|
790.4–790.5
|
Nonspecific findings on examination of blood
|
|
790.7
|
Bacteremia
|
|
791.0–791.7
|
Nonspecific findings on examination of urine
|
|
791.9
|
Other non-specific findings on examination of urine
|
List K
Medicare is establishing the following limited coverage for human papillomavirus (87621):
Covered for:
|
622.10–622.12
|
Dysplasia of cervix (uteri)
|
|
795.00–795.01
|
Abnormal Papanicolaou smear of cervix and cervix HPV
|
|
795.03
|
Papanicolaou smear of cervix with low grade squamous intraepithelial lesion (LGSIL)
|
List L
Medicare is establishing the following limited coverage for Group A Streptococcus (87650):
Covered for:
|
034.0–034.1
|
Streptococcal sore throat and scarlet fever
|
|
040.0
|
Gas gangrene
|
|
040.82
|
Toxic shock syndrome
|
|
288.66
|
Bandemia
|
|
288.8
|
Other specified disease of white blood cells
|
|
388.70
|
Otalgia, unspecified
|
|
388.72
|
Otalgia, referred pain
|
|
390
|
Rheumatic fever without mention of heart involvement
|
|
391.0–391.2
|
Rheumatic fever with heart involvement
|
|
391.8–391.9
|
Rheumatic fever with heart involvement
|
|
421.0–421.1
|
Acute and subacute endocarditis
|
|
421.9
|
Acute endocarditis, unspecified
|
|
460
|
Acute nasopharyngitis [common cold]
|
|
462
|
Acute pharyngitis
|
|
463
|
Acute tonsillitis
|
|
580.0
|
Acute glomerulonephritis, with lesion of proliferative glomerulonephritis
|
|
580.4
|
Acute glomerulonephritis, with lesion of rapidly progressive glomerulonephritis
|
|
580.81
|
Acute glomerulonephritis in diseases classified elsewhere
|
|
580.89
|
Acute glomerulonephritis with other specified pathological lesion in kidney
|
|
580.9
|
Acute glomerulonephritis with unspecified pathological lesion in kidney
|
|
681.00–681.02
|
Cellulitis and abscess of finger
|
|
681.10–681.11
|
Cellulitis and abscess of toe
|
|
681.9
|
Cellulitis and abscess of unspecified digit
|
|
682.0–682.9
|
Other cellulitis and abscess
|
|
728.0
|
Infective myositis
|
|
780.32
|
Complex febrile convulsions
|
|
780.60–780.61
|
Fever
|
|
784.0
|
Headache
|
|
787.03
|
Vomiting alone
|
|
789.00
|
Abdominal pain, unspecified site
|
|
999.5
|
Other serum reaction
|
List M
Medicare is establishing the following limited coverage for Staphylococcus aureus (87640), Methicillin-resistantStaphylococcus aureus (87641), Group B Streptococcus (87653) and Vancomycin-resistant Enterococcus (87500):
Covered for: