Medicare National and Local Coverage Determination Policy – TX
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
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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 TX
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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
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Last Updated:
08/13/2015
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy - TX
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
691.8
708.0
708.3
989.5
989.82
995.0
995.60
995.61
995.62
995.63
995.64
995.65
995.66
995.67
995.68
995.69
V12.00*
V67.59
Aspergillosis
Other Atopic Dermatitis And Related Conditions
Allergic Urticaria
Dermatographic Urticaria
Toxic Effect Of Venom
Toxic Effect Of Latex
OTHER ANAPHYLACTIC Reaction
Anaphylactic Reaction Due To Unspecified Food
Anaphylactic Reaction Due To Peanuts
Anaphylactic Reaction Due To Crustaceans
Anaphylactic Reaction Due To Fruits And Vegetables
Anaphylactic Reaction Due To Tree Nuts And Seeds
Anaphylactic Reaction Due To Fish
Anaphylactic Reaction Due To Food Additives
Anaphylactic Reaction Due To Milk Products
Anaphylactic Reaction Due To Eggs
Anaphylactic Reaction Due To Other Specified Food
Personal History Of Unspecified Infectious And Parasitic Disease
Other Follow-up Examination
*Note: V12.00 Personal History of infectious and parasitic disease should be used for recurrent pyogenic infections.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
08/13/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy - TX
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.
FOR CPT 86003 ONLY
372.00
372.05
372.13
372.14
381.01
381.3
382.9
461.0
461.1
461.2
461.3
461.8
461.9
462
463
464.00
464.01
464.50
464.51
466.0
471.0
471.8
471.9
473.0
473.1
Acute Conjunctivitis Unspecified
Acute Atopic Conjunctivitis
Vernal Conjunctivitis
Other Chronic Allergic Conjunctivitis
Acute Serous Otitis Media
Other And Unspecified Chronic Nonsuppurative Otitis Media
Unspecified Otitis Media
Acute Maxillary Sinusitis
Acute Frontal Sinusitis
Acute Ethmoidal Sinusitis
Acute Sphenoidal Sinusitis
Other Acute Sinusitis
Acute Sinusitis Unspecified
Acute Pharyngitis
Acute Tonsillitis
Acute Laryngitis Without Obstruction
Acute Laryngitis With Obstruction
Supraglottitis Unspecified Without Obstruction
Supraglottitis Unspecified With Obstruction
Acute Bronchitis
Polyp Of Nasal Cavity
Other Polyp Of Sinus
Unspecified Nasal Polyp
Chronic Maxillary Sinusitis
Chronic Frontal Sinusitis
473.2
477.0
477.8
477.9
478.0
478.19
493.00
493.01
493.02
493.10
493.11
493.12
493.20
493.21
493.22
493.81
493.82
493.90
493.91
493.92
535.40
691.8
693.1
698.9
708.0
Chronic Ethmoidal Sinusitis
Allergic Rhinitis Due To Pollen
Allergic Rhinitis Due To Other Allergen
Allergic Rhinitis Cause Unspecified
Hypertrophy Of Nasal Turbinates
Other Disease Of Nasal Cavity And Sinuses
Extrinsic Asthma Unspecified
Extrinsic Asthma With Status Asthmaticus
Extrinsic Asthma With (Acute) Exacerbation
Intrinsic Asthma Unspecified
Intrinsic Asthma With Status Asthmaticus
Intrinsic Asthma With (Acute) Exacerbation
Chronic Obstructive Asthma Unspecified
Chronic Obstructive Asthma With Status Asthmaticus
Chronic Obstructive Asthma With (Acute) Exacerbation
Exercise-induced Bronchospasm
Cough Variant Asthma
Asthma Unspecified
Asthma Unspecified Type With Status Asthmaticus
Asthma Unspecified With (Acute) Exacerb
Other Specified Gastritis (Without Hemorrhage)
Other Atopic Dermatitis And Related Conditions
Dermatitis Due To Food Taken Internally
Unspecified Pruritic Disorder
Allergic Urticaria
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
08/13/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy - TX
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
708.8
708.9
786.09
786.2
989.5
995.0
995.1
995.20
995.27
995.29
995.3
999.41
999.42
999.49
999.51
999.52
999.59
V14.0
Idiopathic Urticaria
Other Specified Urticaria
Unspecified Urticaria
Respiratory Abnormality Other
Cough
Toxic Effect Of Venom
Other Anaphylactic Reaction
Angioneurotic Edema Not Elsewhere Classified
Unspecified Adverse Effect Of Unspecified Drug,
Medicinal And Biological Substance
Other Drug Allergy
Unspecified Adverse Effect Of Other Drug, Medicinal And
Biological Substance
Allergy Unspecified Not Elsewhere Classified
Anaphylactic Reaction Due To Administration Of Blood
And Blood Products
Anaphylactic Reaction Due To Vaccination
Anaphylactic Reaction Due To Other Serum
Other Serum Reaction Due To Administration Of Blood
And Blood Products
Other Serum Reaction Due To Vaccination
Other Serum Reaction
Personal History Of Allergy To Penicillin
V14.1
V14.2
V14.3
V14.4
V14.5
V14.6
V14.7
V14.8
V14.9
V15.01
V15.02
V15.03
V15.04
V15.05
V15.06
V15.07
V15.08
V15.09
Personal History Of Allergy To Other Antibiotic
Agent
Personal History Of Allergy To Sulfonamides
Personal History Of Allergy To Other Anti-infective
Agent
Personal History Of Allergy To Anesthetic Agent
Personal History Of Allergy To Narcotic Agent
Personal History Of Allergy To Analgesic Agent
Personal History Of Allergy To Serum Or Vaccine
Personal History Of Allergy To Other Specified
Medicinal Agents
Personal History Of Allergy To Unspecified
Medicinal Agent
Personal History Of Allergy To Peanuts
Personal History Of Allergy To Milk Products
Personal History Of Allergy To Eggs
Personal History Of Allergy To Seafood
Personal History Of Allergy To Other Foods
Allergy To Insects And Arachnids
Personal History Of Allergy To Latex
Personal History Of Allergy To Radiographic Dye
Personal History Of Other Allergy Other Than To
Medicinal Agents
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
08/13/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy - TX
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
261
262
263 .0
263.2
Whipple's Disease
Nutritional Marasmus
Other Severe Protein-Calorie Malnutrition
Malnutrition Of Moderate Degree
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
356.9
529 .0
529.6
536 .0
555.0 - 555.2
555.9
579.0 - 579.4
579.8 - 579.9
780.93
780.99*
781.2
781.3
782 .0
V12.1
V45.11
V45.3
V58.11
V58.69
Idiopathic Progressive Polyneuropathy
Unspecified Idiopathic Peripheral Neuropathy
Glossitis
Glossodynia
Achlorhydria
Regional Enteritis Of Small Intestine - Regional Enteritis
Of Small Intestine With Large Intestine
Regional Enteritis Of Unspecified Site
Celiac Disease - Pancreatic Steatorrhea
Other Specified Intestinal Malabsorption - Unspecified
Intestinal Malabsorption
Memory Loss
Other General Symptoms
*Note: Use code 780.99 to identify altered mental status
Abnormality Of Gait
Lack Of Coordination
Disturbance Of Skin Sensation
Personal History Of Nutritional Deficiency
Renal Dialysis Status
Postsurgical Intestinal Bypass Or Anastomosis Status
Encounter For Antineoplastic Chemotherapy
Long-Term (Current) Use Of Other Medications
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
285.21
458.21
Primary Carnitine Deficiency - Other Secondary Carnitine Deficiency
Anemia In Chronic Kidney Disease
Hypotension Of Hemodialysis
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
996.81 - 996.88
V42.0
V42.1
V42.6
V42.7
V42.81
V42.83
V42.84
Immunodeficiency With Predominant T-Cell Defect Unspecified - Nezelof's Syndrome
Complications Of Transplanted Kidney - Complications Of Transplanted Organ, Stem Cell
Kidney Replaced By Transplant
Heart Replaced By Transplant
Lung Replaced By Transplant
Liver Replaced By Transplant
Bone Marrow Replaced By Transplant
Pancreas Replaced By Transplant
Organ Or Tissue Replaced By Transplant Intestines
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source:
Medicare Local Coverage Determination Policy - TX
L36214 Assays for Vitamins and Metabolic Function – Fibrinogen
www.cms.gov
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy - TX
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
261
262
263 .0
263.2
Whipple's Disease
Nutritional Marasmus
Other Severe Protein-Calorie Malnutrition
Malnutrition Of Moderate Degree
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
356.9
529 .0
529.6
536 .0
555.0 - 555.2
555.9
579.0 - 579.4
579.8 - 579.9
780.93
780.99*
781.2
781.3
782 .0
V12.1
V45.11
V45.3
V58.11
V58.69
Idiopathic Progressive Polyneuropathy
Unspecified Idiopathic Peripheral Neuropathy
Glossitis
Glossodynia
Achlorhydria
Regional Enteritis Of Small Intestine - Regional Enteritis
Of Small Intestine With Large Intestine
Regional Enteritis Of Unspecified Site
Celiac Disease - Pancreatic Steatorrhea
Other Specified Intestinal Malabsorption - Unspecified
Intestinal Malabsorption
Memory Loss
Other General Symptoms
*Note: Use code 780.99 to identify altered mental status
Abnormality Of Gait
Lack Of Coordination
Disturbance Of Skin Sensation
Personal History Of Nutritional Deficiency
Renal Dialysis Status
Postsurgical Intestinal Bypass Or Anastomosis Status
Encounter For Antineoplastic Chemotherapy
Long-Term (Current) Use Of Other Medications
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
05/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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 A2 (LpPLA2) 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
250.02
272.0
272.1
272.2
272.3
272.4
414.01
414.4
Diabetes Mellitus Without Mention Of Complication, Type Ii Or Unspecified Type, Not Stated As
Uncontrolled
Diabetes Mellitus Without Mention Of Complication, Type Ii Or Unspecified Type, Uncontrolled
Pure Hypercholesterolemia
Pure Hyperglyceridemia
Mixed Hyperlipidemia
Hyperchylomicronemia
Other And Unspecified Hyperlipidemia
Coronary Atherosclerosis Of Native Coronary Artery
Coronary Atherosclerosis Due To Calcified Coronary Lesion
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy - TX
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
285.0
333.99
356.9
529.0
Vitamin B6 Deficiency
Sideroblastic Anemia
Other Extrapyramidal Diseases And Abnormal Movement Disorders
Unspecified Idiopathic Peripheral Neuropathy
Glossitis
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
3
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
261
262
263 .0
263.2
Whipple's Disease
Nutritional Marasmus
Other Severe Protein-Calorie Malnutrition
Malnutrition Of Moderate Degree
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
356.9
529 .0
529.6
536 .0
555.0 - 555.2
555.9
579.0 - 579.4
579.8 - 579.9
780.93
780.99*
781.2
781.3
782 .0
V12.1
V45.11
V45.3
V58.11
V58.69
Idiopathic Progressive Polyneuropathy
Unspecified Idiopathic Peripheral Neuropathy
Glossitis
Glossodynia
Achlorhydria
Regional Enteritis Of Small Intestine - Regional Enteritis
Of Small Intestine With Large Intestine
Regional Enteritis Of Unspecified Site
Celiac Disease - Pancreatic Steatorrhea
Other Specified Intestinal Malabsorption - Unspecified
Intestinal Malabsorption
Memory Loss
Other General Symptoms
*Note: Use code 780.99 to identify altered mental status
Abnormality Of Gait
Lack Of Coordination
Disturbance Of Skin Sensation
Personal History Of Nutritional Deficiency
Renal Dialysis Status
Postsurgical Intestinal Bypass Or Anastomosis Status
Encounter For Antineoplastic Chemotherapy
Long-Term (Current) Use Of Other Medications
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy - TX
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
252.08
252.1
268.0
268.2
268.9
275.3
275.41 - 275.42
585.3 - 585.6
588.81
733.00 - 733.03
733.09
733.90
Hyperparathyroidism, Unspecified - Secondary Hyperparathyroidism, Non-Renal
Other Hyperparathyroidism
Hypoparathyroidism
Rickets Active
Osteomalacia Unspecified
Unspecified Vitamin D Deficiency
Disorders Of Phosphorus Metabolism
Hypocalcemia - Hypercalcemia
Chronic Kidney Disease, Stage III (Moderate) - End Stage Renal Disease
Secondary Hyperparathyroidism (Of Renal Origin)
Osteoporosis Unspecified - Disuse Osteoporosis
Other Osteoporosis
Disorder Of Bone And Cartilage Unspecified
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
252.08
252.1
268.0
268.2
268.9
275.3
275.41 - 275.42
585.3 - 585.6
588.81
733.00 - 733.03
733.09
733.90
Hyperparathyroidism, Unspecified - Secondary Hyperparathyroidism, Non-Renal
Other Hyperparathyroidism
Hypoparathyroidism
Rickets Active
Osteomalacia Unspecified
Unspecified Vitamin D Deficiency
Disorders Of Phosphorus Metabolism
Hypocalcemia - Hypercalcemia
Chronic Kidney Disease, Stage III (Moderate) - End Stage Renal Disease
Secondary Hyperparathyroidism (Of Renal Origin)
Osteoporosis Unspecified - Disuse Osteoporosis
Other Osteoporosis
Disorder Of Bone And Cartilage Unspecified
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source:
Medicare Local Coverage Determination Policy - TX
L32614 Assays for Vitamins and Metabolic Function – Non-Covered
Services/Frequency Limitations
CPT Codes: 82180, 84252, 84255, 84425, 84446, 84590, 84591, 84597, 84999
www.cms.gov
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
84591
84999
84999
Assays of selenium
Assays of vitamin testing, not otherwise classified
Functional Intracellular Analysis
Total Antioxidant Function
Frequency Limitations
82180
84252
84425
84446
84590
84597
Assay of ascorbic acid
Assay of vitamin b-2
Assay of vitamin b-1
Assay of vitamin e
Assay of vitamin a
Assay of vitamin k
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy – TX
L34796 Biomarkers for Oncology (Page 1 of 21)
Data Source: www.cms.gov
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
152.1
152.2
152.3
152.8
152.9
153.0
153.1
153.2
153.3
153.4
153.5
153.6
153.7
153.8
153.9
MALIGNANT NEOPLASM OF DUODENUM
MALIGNANT NEOPLASM OF JEJUNUM
MALIGNANT NEOPLASM OF ILEUM
MALIGNANT NEOPLASM OF MECKEL'S DIVERTICULUM
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF SMALL INTESTINE
MALIGNANT NEOPLASM OF SMALL INTESTINE UNSPECIFIED SITE
MALIGNANT NEOPLASM OF HEPATIC FLEXURE
MALIGNANT NEOPLASM OF TRANSVERSE COLON
MALIGNANT NEOPLASM OF DESCENDING COLON
MALIGNANT NEOPLASM OF SIGMOID COLON
MALIGNANT NEOPLASM OF CECUM
MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS
MALIGNANT NEOPLASM OF ASCENDING COLON
MALIGNANT NEOPLASM OF SPLENIC FLEXURE
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE
MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
162.2
162.3
162.4
162.5
162.8
162.9
163.0
163.1
163.8
163.9
MALIGNANT NEOPLASM OF TRACHEA
MALIGNANT NEOPLASM OF MAIN BRONCHUS
MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG
MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG
MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG
MALIGNANT NEOPLASM OF OTHER PARTS OF
BRONCHUS OR LUNG
MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED
MALIGNANT NEOPLASM OF PARIETAL PLEURA
MALIGNANT NEOPLASM OF VISCERAL PLEURA
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PLEURA
MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
172.1
172.2
172.3
172.4
172.5
172.6
172.7
172.8
172.9
MALIGNANT MELANOMA OF SKIN OF LIP
MALIGNANT MELANOMA OF SKIN OF EYELID INCLUDING CANTHUS
MALIGNANT MELANOMA OF SKIN OF EAR AND EXTERNAL AUDITORY CANAL
MALIGNANT MELANOMA OF SKIN OF OTHER AND UNSPECIFIED PARTS OF FACE
MALIGNANT MELANOMA OF SKIN OF SCALP AND NECK
MALIGNANT MELANOMA OF SKIN OF TRUNK EXCEPT SCROTUM
MALIGNANT MELANOMA OF SKIN OF UPPER LIMB INCLUDING SHOULDER
MALIGNANT MELANOMA OF SKIN OF LOWER LIMB INCLUDING HIP
MALIGNANT MELANOMA OF OTHER SPECIFIED SITES OF SKIN
MELANOMA OF SKIN SITE UNSPECIFIED
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
191.1
191.2
191.3
191.4
191.5
191.6
191.7
191.8
191.9
MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES
MALIGNANT NEOPLASM OF FRONTAL LOBE
MALIGNANT NEOPLASM OF TEMPORAL LOBE
MALIGNANT NEOPLASM OF PARIETAL LOBE
MALIGNANT NEOPLASM OF OCCIPITAL LOBE
MALIGNANT NEOPLASM OF VENTRICLES
MALIGNANT NEOPLASM OF CEREBELLUM NOS
MALIGNANT NEOPLASM OF BRAIN STEM
MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN
MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
226
237.4
241.0
241.1
246.2
MALIGNANT NEOPLASM OF THYROID GLAND
BENIGN NEOPLASM OF THYROID GLANDS
NEOPLASM OF UNCERTAIN BEHAVIOR OF OTHER AND UNSPECIFIED ENDOCRINE GLANDS
NONTOXIC UNINODULAR GOITER
NONTOXIC MULTINODULAR GOITER
CYST OF THYROID
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
158.9
182.0
182.1
182.8
183.0
183.2
183.3
183.4
183.5
183.8
183.9
MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM
MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED
MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS
MALIGNANT NEOPLASM OF ISTHMUS
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BODY OF UTERUS
MALIGNANT NEOPLASM OF OVARY
MALIGNANT NEOPLASM OF FALLOPIAN TUBE
MALIGNANT NEOPLASM OF BROAD LIGAMENT OF UTERUS
MALIGNANT NEOPLASM OF PARAMETRIUM
MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA
MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
189.2
189.3
189.4
189.8
189.9
MALIGNANT NEOPLASM OF RENAL PELVIS
MALIGNANT NEOPLASM OF URETER
MALIGNANT NEOPLASM OF URETHRA
MALIGNANT NEOPLASM OF PARAURETHRAL GLANDS
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF URINARY ORGANS
MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
600.00
600.01
600.10
600.11
600.20
600.21
600.3
600.90
600.91
MALIGNANT NEOPLASM OF PROSTATE
HYPERTROPHY (BENIGN) OF PROSTATE WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT (LUTS)
HYPERTROPHY (BENIGN) OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS (LUTS)
NODULAR PROSTATE WITHOUT URINARY OBSTRUCTION
NODULAR PROSTATE WITH URINARY OBSTRUCTION
BENIGN LOCALIZED HYPERPLASIA OF PROSTATE WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT
SYMPTOMS (LUTS)
BENIGN LOCALIZED HYPERPLASIA OF PROSTATE WITH URINARY OBSTRUCTION AND OTHER LOWER URINARY TRACT SYMPTOMS LUTS)
CYST OF PROSTATE
HYPERPLASIA OF PROSTATE, UNSPECIFIED, WITHOUT URINARY OBSTRUCTION AND OTHER LOWER URINARY SYMPTOMS LUTS)
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
204.01
204.02
ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
LYMPHOID LEUKEMIA ACUTE IN REMISSION
ACUTE LYMPHOID LEUKEMIA, IN RELAPSE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
RUNX1/RUNX1T1 81401
CBFB/MYH11 81401
FLT3 ITD 81245
FLT3 D836 81479
NPM1 81310
KRAS 81275, 81403, 81479
NRAS 81404
KIT 81402
CEBPA 81403
IDH1 81403
IDH2 81403
DNMT3A 81403
JAK2 (p.V617F) 81270
JAK2 (exon 12) 81403
MPL 81402
DEK/CAN 81479
ASXL1 81479
EZH2 81479
TET2 81479
Group 11 Codes
205.00
205.01
205.02
ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
MYELOID LEUKEMIA ACUTE IN REMISSION
ACUTE MYELOID LEUKEMIA, IN RELAPSE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
L34796 Biomarkers for Oncology (Page 11 of 21)
Data Source: www.cms.gov
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
202.41
202.42
202.43
202.44
202.45
202.46
202.47
202.48
LEUKEMIC RETICULOENDOTHELIOSIS
LEUKEMIC RETICULOENDOTHELIOSIS
LEUKEMIC RETICULOENDOTHELIOSIS
LEUKEMIC RETICULOENDOTHELIOSIS
LEUKEMIC RETICULOENDOTHELIOSIS
LEUKEMIC RETICULOENDOTHELIOSIS
LEUKEMIC RETICULOENDOTHELIOSIS
LEUKEMIC RETICULOENDOTHELIOSIS
LEUKEMIC RETICULOENDOTHELIOSIS
UNSPECIFIED SITE
INVOLVING LYMPH NODES OF HEAD FACE AND NECK
INVOLVING INTRATHORACIC LYMPH NODES
INVOLVING INTRA-ABDOMINAL LYMPH NODES
INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM
INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
INVOLVING INTRAPELVIC LYMPH NODES
INVOLVING SPLEEN
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
284.09
284.81
284.89
284.9
CONSTITUTIONAL RED BLOOD CELL APLASIA
OTHER CONSTITUTIONAL APLASTIC ANEMIA
RED CELL APLASIA (ACQUIRED) (ADULT) (WITH THYMOMA)
OTHER SPECIFIED APLASTIC ANEMIAS
APLASTIC ANEMIA UNSPECIFIED
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
200.21
200.22
200.23
200.24
200.25
200.26
200.27
200.28
BURKITT'S
BURKITT'S
BURKITT'S
BURKITT'S
BURKITT'S
BURKITT'S
BURKITT'S
BURKITT'S
BURKITT'S
TUMOR
TUMOR
TUMOR
TUMOR
TUMOR
TUMOR
TUMOR
TUMOR
TUMOR
OR LYMPHOMA
OR LYMPHOMA
OR LYMPHOMA
OR LYMPHOMA
OR LYMPHOMA
OR LYMPHOMA
OR LYMPHOMA
OR LYMPHOMA
OR LYMPHOMA
UNSPECIFIED SITE
INVOLVING LYMPH NODES OF HEAD FACE AND NECK
INVOLVING INTRATHORACIC LYMPH NODES
INVOLVING INTRA-ABDOMINAL LYMPH NODES
INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
INVOLVING INTRAPELVIC LYMPH NODES
INVOLVING SPLEEN
INVOLVING LYMPH NODES OF MULTIPLE SITES
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
238.71
238.76
289.83
POLYCYTHEMIA VERA
ESSENTIAL THROMBOCYTHEMIA
MYELOFIBROSIS WITH MYELOID METAPLASIA
MYELOFIBROSIS
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
205.11
205.12
CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
MYELOID LEUKEMIA CHRONIC IN REMISSION
CHRONIC MYELOID LEUKEMIA, IN RELAPSE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
204.11
204.12
CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
LYMPHOID LEUKEMIA CHRONIC IN REMISSION
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
202.01
202.02
202.03
202.04
202.05
202.06
202.07
202.08
NODULAR LYMPHOMA UNSPECIFIED SITE
NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK
NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES
NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES
NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES
NODULAR LYMPHOMA INVOLVING SPLEEN
NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
200.41
200.42
200.43
200.44
200.45
200.46
200.47
200.48
MANTLE
MANTLE
MANTLE
MANTLE
MANTLE
MANTLE
MANTLE
MANTLE
MANTLE
CELL LYMPHOMA,
CELL LYMPHOMA,
CELL LYMPHOMA,
CELL LYMPHOMA,
CELL LYMPHOMA,
CELL LYMPHOMA,
CELL LYMPHOMA,
CELL LYMPHOMA,
CELL LYMPHOMA,
UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES
LYMPH NODES OF HEAD, FACE, AND NECK
INTRATHORACIC LYMPH NODES
INTRA-ABDOMINAL LYMPH NODES
LYMPH NODES OF AXILLA AND UPPER LIMB
LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
INTRAPELVIC LYMPH NODES
SPLEEN
LYMPH NODES OF MULTIPLE SITES
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
202.61
202.62
202.63
202.64
202.65
202.66
202.67
202.68
MALIGNANT MAST CELL TUMORS
MALIGNANT MAST CELL TUMORS
MALIGNANT MAST CELL TUMORS
MALIGNANT MAST CELL TUMORS
MALIGNANT MAST CELL TUMORS
MALIGNANT MAST CELL TUMORS
MALIGNANT MAST CELL TUMORS
MALIGNANT MAST CELL TUMORS
MALIGNANT MAST CELL TUMORS
UNSPECIFIED SITE
INVOLVING LYMPH NODES OF HEAD FACE AND NECK
INVOLVING INTRATHORACIC LYMPH NODES
INVOLVING INTRA-ABDOMINAL LYMPH NODES
INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB
INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB
INVOLVING INTRAPELVIC LYMPH NODES
INVOLVING SPLEEN
INVOLVING LYMPH NODES OF MULTIPLE SITES
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
208.91
208.92
UNSPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
UNSPECIFIED LEUKEMIA IN REMISSION
UNSPECIFIED LEUKEMIA, IN RELAPSE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
FLT3 D836 81479
NPM1 81310
KRAS 81275, 81403, 81479
NRAS 81404
KIT 81402
CEBPA 81403
IDH1 81403
IDH2 81403
DNMT3A 81403
JAK2 (p.V617F) 81270
JAK2 (exon 12) 81403
MPL 81402
ASXL1 81479
EZH2 81479
TET2 81479
Group 23 Codes
238.72
238.73
238.74
238.75
LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS
HIGH GRADE MYELODYSPLASTIC SYNDROME LESIONS
MYELODYSPLASTIC SYNDROME WITH 5Q DELETION
MYELODYSPLASTIC SYNDROME, UNSPECIFIED
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
203.01
203.02
204.10
205.00
206.00
206.01
206.02
206.10
207.00
238.6
238.72
238.73
238.74
238.75
273.0
273.1
MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
MULTIPLE MYELOMA IN REMISSION
MULTIPLE MYELOMA, IN RELAPSE
CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
MONOCYTIC LEUKEMIA ACUTE IN REMISSION
ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE
CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
NEOPLASM OF UNCERTAIN BEHAVIOR OF PLASMA CELLS
LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS
HIGH GRADE MYELODYSPLASTIC SYNDROME LESIONS
MYELODYSPLASTIC SYNDROME WITH 5Q DELETION
MYELODYSPLASTIC SYNDROME, UNSPECIFIED
POLYCLONAL HYPERGAMMAGLOBULINEMIA
MONOCLONAL PARAPROTEINEMIA
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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*
203.02*
MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
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.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
06/05/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
81202
81203
81211
81212
81213
81214
81215
81216
81217
81240
81241
Apc gene full sequence
Apc gene known fam variants
Apc gene dup/delet variants
Brca1&2 seq & com dup/del
Brca1&2 185&5385&6174 var
Brca1&2 uncom dup/del var
Brca1 full seq & com dup/del
Brca1 gene known fam variant
Brca2 gene full sequence
Brca2 gene known fam variant
F2 gene
F5 gene
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
81293
81294
81301
81321
81322
81323
Mlh 1 gene full seq
Mlh 1 gene known variants
Mlh 1 gene dup/delete variant
Microsatellite instability
Pten gene full sequence
Pten gene known fam variant
Pten gene dup/delet variant
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
81251
81252
81253
81254
81255
81290
G6pc gene
Gba gene
Gjb2 gene full sequence
Gjb2 gene known fam variants
Gjb6 gene com variants
Hexa gene
Mcoln1 gene
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
81325
81252
Pmp22 gene dup/delet
Pmp22 gene full sequence
Pmp22 gene known fam variant
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
81256
81257
81295
81296
81297
81298
81299
81300
81317
81318
81319
81332
Fancc gene
Hfe gene
Hba1/hba2 gene
Msh2 gene full seq
Msh2 gene known variants
Msh2 gene dup/delete variant
Msh6 gene full seq
Msh6 gene known variants
Msh6 gene dup/delete variant
Pms2 gene full seq analysis
Pms2 known familial variants
Pms2 gene dup/delet variants
Serpina1 gene
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
Data Source: www.cms.gov
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
Non Covered Codes
81161
81200
81205
81209
81220
81221
81222
81223
81224
81243
81244
81260
81280
81281
81282
81302
81303
81304
81330
81331
Dmd dup/delet analysis
Aspa gene
Bckdhb gene
Blm gene
Cftr gene com variants
Cftr gene known fam variants
Cftr gene dup/delet variants
Cftr gene full sequence
Cftr gene intron poly t
Fmr1 gene detection
Fmr1 gene characterization
Ikbkap gene
Long qt synd gene full sequence
Long qt synd known fam var
Long qt syn gene dup/dlt var
Mecp2 gene full seq
Mecp2 gene known variant
Mecp2 gene dup/delet variant
Smpd1 gene common variants
Snrpn/ube3a gene
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
151.9
MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE
152.0
152.1
152.2
152.8
152.9
153.0 - 153.9
154.0
154.1
154.2
154.3
154.8
MALIGNANT NEOPLASM OF DUODENUM
MALIGNANT NEOPLASM OF JEJUNUM
MALIGNANT NEOPLASM OF ILEUM
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
SMALL INTESTINE
MALIGNANT NEOPLASM OF SMALL INTESTINE
UNSPECIFIED SITE
MALIGNANT NEOPLASM OF HEPATIC FLEXURE MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE
MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION
MALIGNANT NEOPLASM OF RECTUM
MALIGNANT NEOPLASM OF ANAL CANAL
MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE
MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM
RECTOSIGMOID JUNCTION AND ANUS
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
155.2
156.0
156.1
156.2
157.0
157.1
157.2
157.8
157.9
158.0
158.8
158.9
MALIGNANT NEOPLASM OF LIVER PRIMARY
MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY
OR SECONDARY
MALIGNANT NEOPLASM OF GALLBLADDER
MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS
MALIGNANT NEOPLASM OF AMPULLA OF VATER
MALIGNANT NEOPLASM OF HEAD OF PANCREAS
MALIGNANT NEOPLASM OF BODY OF PANCREAS
MALIGNANT NEOPLASM OF TAIL OF PANCREAS
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
PANCREAS
MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED
MALIGNANT NEOPLASM OF RETROPERITONEUM
MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM
MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED
159.0
159.1
159.8
159.9
160.0
160.1
160.2
160.3
160.4
160.5
160.8
MALIGNANT NEOPLASM OF INTESTINAL TRACT PART
UNSPECIFIED
MALIGNANT NEOPLASM OF SPLEEN NOT ELSEWHERE
CLASSIFIED
MALIGNANT NEOPLASM OF OTHER SITES OF DIGESTIVE
SYSTEM AND INTRA-ABDOMINAL ORGANS
MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE
DIGESTIVE ORGANS AND PERITONEUM
MALIGNANT NEOPLASM OF NASAL CAVITIES
MALIGNANT NEOPLASM OF AUDITORY TUBE MIDDLE EAR
AND MASTOID AIR CELLS
MALIGNANT NEOPLASM OF MAXILLARY SINUS
MALIGNANT NEOPLASM OF ETHMOIDAL SINUS
MALIGNANT NEOPLASM OF FRONTAL SINUS
MALIGNANT NEOPLASM OF SPHENOIDAL SINUS
MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
161.0
161.1
161.2
161.3
161.8
161.9
162.0
162.2
162.3
162.4
162.5
162.8
MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED
MALIGNANT NEOPLASM OF GLOTTIS
MALIGNANT NEOPLASM OF SUPRAGLOTTIS
MALIGNANT NEOPLASM OF SUBGLOTTIS
MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
LARYNX
MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED
MALIGNANT NEOPLASM OF TRACHEA
MALIGNANT NEOPLASM OF MAIN BRONCHUS
MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG
MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG
MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG
MALIGNANT NEOPLASM OF OTHER PARTS OF
BRONCHUS OR LUNG
162.9
163.0
163.1
163.8
163.9
164.0
164.2
164.3
164.8
164.9
165.0
MALIGNANT NEOPLASM OF BRONCHUS AND LUNG
UNSPECIFIED
MALIGNANT NEOPLASM OF PARIETAL PLEURA
MALIGNANT NEOPLASM OF VISCERAL PLEURA
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
PLEURA
MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED
MALIGNANT NEOPLASM OF THYMUS
MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM
MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM
MALIGNANT NEOPLASM OF OTHER PARTS OF
MEDIASTINUM
MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSPECIFIED
MALIGNANT NEOPLASM OF UPPER RESPIRATORY TRACT
PART UNSPECIFIED
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
165.9
170.0
170.2
170.3
170.4
170.5
170.6
MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE
RESPIRATORY SYSTEM AND INTRATHORACIC ORGANS
MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN
THE RESPIRATORY SYSTEM
MALIGNANT NEOPLASM OF BONES OF SKULL AND FACE
EXCEPT MANDIBLE
MALIGNANT NEOPLASM OF VERTEBRAL COLUMN
EXCLUDING SACRUM AND COCCYX
MALIGNANT NEOPLASM OF RIBS STERNUM AND
CLAVICLE
MALIGNANT NEOPLASM OF SCAPULA AND LONG BONES
OF UPPER LIMB
MALIGNANT NEOPLASM OF SHORT BONES OF UPPER
LIMB
MALIGNANT NEOPLASM OF PELVIC BONES SACRUM AND
COCCYX
170.7
170.8
170.9
171.0
171.2
171.3
171.4
171.5
MALIGNANT NEOPLASM OF LONG BONES OF LOWER
LIMB
MALIGNANT NEOPLASM OF SHORT BONES OF LOWER
LIMB
MALIGNANT NEOPLASM OF BONE AND ARTICULAR
CARTILAGE SITE UNSPECIFIED
MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER
SOFT TISSUE OF HEAD FACE AND NECK
MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER
SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER
MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER
SOFT TISSUE OF LOWER LIMB INCLUDING HIP
MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER
SOFT TISSUE OF THORAX
MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER
SOFT TISSUE OF ABDOMEN
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
171.7
171.8
171.9
173.00
173.01
173.02
173.09
173.10
MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER
SOFT TISSUE OF PELVIS
MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER
SOFT TISSUE OF TRUNK UNSPECIFIED
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
CONNECTIVE AND OTHER SOFT TISSUE
MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER
SOFT TISSUE SITE UNSPECIFIED
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF LIP
BASAL CELL CARCINOMA OF SKIN OF LIP
SQUAMOUS CELL CARCINOMA OF SKIN OF LIP
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF
LIP
UNSPECIFIED MALIGNANT NEOPLASM OF EYELID,
INCLUDING CANTHUS
173.11
173.12
173.19
173.20
173.21
173.22
173.29
173.30
BASAL CELL CARCINOMA OF EYELID, INCLUDING
CANTHUS
SQUAMOUS CELL CARCINOMA OF EYELID, INCLUDING
CANTHUS
OTHER SPECIFIED MALIGNANT NEOPLASM OF EYELID,
INCLUDING CANTHUS
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF EAR
AND EXTERNAL AUDITORY CANAL
BASAL CELL CARCINOMA OF SKIN OF EAR AND
EXTERNAL AUDITORY CANAL
SQUAMOUS CELL CARCINOMA OF SKIN OF EAR AND
EXTERNAL AUDITORY CANAL
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF
EAR AND EXTERNAL AUDITORY CANAL
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF
OTHER AND UNSPECIFIED PARTS OF FACE
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
173.32
173.39
173.40
173.41
173.42
173.49
173.50
BASAL CELL CARCINOMA OF SKIN OF OTHER AND
UNSPECIFIED PARTS OF FACE
SQUAMOUS CELL CARCINOMA OF SKIN OF OTHER AND
UNSPECIFIED PARTS OF FACE
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF
OTHER AND UNSPECIFIED PARTS OF FACE
UNSPECIFIED MALIGNANT NEOPLASM OF SCALP AND
SKIN OF NECK
BASAL CELL CARCINOMA OF SCALP AND SKIN OF NECK
SQUAMOUS CELL CARCINOMA OF SCALP AND SKIN OF
NECK
OTHER SPECIFIED MALIGNANT NEOPLASM OF SCALP
AND SKIN OF NECK
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF
TRUNK, EXCEPT SCROTUM
173.51
173.52
173.59
173.60
173.61
173.62
173.69
173.70
BASAL CELL CARCINOMA OF SKIN OF TRUNK, EXCEPT
SCROTUM
SQUAMOUS CELL CARCINOMA OF SKIN OF TRUNK,
EXCEPT SCROTUM
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF
TRUNK, EXCEPT SCROTUM
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF
UPPER LIMB, INCLUDING SHOULDER
BASAL CELL CARCINOMA OF SKIN OF UPPER LIMB, I
NCLUDING SHOULDER
SQUAMOUS CELL CARCINOMA OF SKIN OF UPPER LIMB,
INCLUDING SHOULDER
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF
UPPER LIMB, INCLUDING SHOULDER
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN OF
LOWER LIMB, INCLUDING HIP
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
173.72
173.79
173.80
173.81
173.82
173.89
173.90
BASAL CELL CARCINOMA OF SKIN OF LOWER LIMB,
INCLUDING HIP
SQUAMOUS CELL CARCINOMA OF SKIN OF LOWER LIMB,
INCLUDING HIP
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN OF
LOWER LIMB, INCLUDING HIP
UNSPECIFIED MALIGNANT NEOPLASM OF OTHER
SPECIFIED SITES OF SKIN
BASAL CELL CARCINOMA OF OTHER SPECIFIED SITES OF
SKIN
SQUAMOUS CELL CARCINOMA OF OTHER SPECIFIED
SITES OF SKIN
OTHER SPECIFIED MALIGNANT NEOPLASM OF OTHER
SPECIFIED SITES OF SKIN
UNSPECIFIED MALIGNANT NEOPLASM OF SKIN, SITE
UNSPECIFIED
173.91
173.92
173.99
174.0 - 174.6
174.8
174.9
175.0
175.9
BASAL CELL CARCINOMA OF SKIN, SITE UNSPECIFIED
SQUAMOUS CELL CARCINOMA OF SKIN, SITE
UNSPECIFIED
OTHER SPECIFIED MALIGNANT NEOPLASM OF SKIN,
SITE UNSPECIFIED
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF
FEMALE BREAST - MALIGNANT NEOPLASM OF AXILLARY
TAIL OF FEMALE BREAST
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
FEMALE BREAST
MALIGNANT NEOPLASM OF BREAST (FEMALE)
UNSPECIFIED SITE
MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF
MALE BREAST
MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED
SITES OF MALE BREAST
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
176.1
176.2
176.3
176.4
176.5
176.8
176.9
179
180.0
180.1
180.8
180.9
181
KAPOSI'S SARCOMA SKIN
KAPOSI'S SARCOMA SOFT TISSUE
KAPOSI'S SARCOMA PALATE
KAPOSI'S SARCOMA GASTROINTESTINAL SITES
KAPOSI'S SARCOMA LUNG
KAPOSI'S SARCOMA LYMPH NODES
KAPOSI'S SARCOMA OTHER SPECIFIED SITES
KAPOSI'S SARCOMA UNSPECIFIED SITE
MALIGNANT NEOPLASM OF UTERUS-PART UNS
MALIGNANT NEOPLASM OF ENDOCERVIX
MALIGNANT NEOPLASM OF EXOCERVIX
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
CERVIX
MALIGNANT NEOPLASM OF CERVIX UTERI UNSPECIFIED
SITE
MALIGNANT NEOPLASM OF PLACENTA
182.0
182.1
182.8
183.0
183.8
184.0
184.1
184.2
184.3
184.4
184.8
MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT
ISTHMUS
MALIGNANT NEOPLASM OF ISTHMUS
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
BODY OF UTERUS
MALIGNANT NEOPLASM OF OVARY
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
UTERINE ADNEXA
MALIGNANT NEOPLASM OF VAGINA
MALIGNANT NEOPLASM OF LABIA MAJORA
MALIGNANT NEOPLASM OF LABIA MINORA
MALIGNANT NEOPLASM OF CLITORIS
MALIGNANT NEOPLASM OF VULVA UNSPECIFIED SITE
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
FEMALE GENITAL ORGANS
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
185
186.0
186.9
187.1
187.2
187.3
187.4
187.5
187.6
187.7
187.8
MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN
SITE UNSPECIFIED
MALIGNANT NEOPLASM OF PROSTATE
MALIGNANT NEOPLASM OF UNDESCENDED TESTIS
MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED
TESTIS
MALIGNANT NEOPLASM OF PREPUCE
MALIGNANT NEOPLASM OF GLANS PENIS
MALIGNANT NEOPLASM OF BODY OF PENIS
MALIGNANT NEOPLASM OF PENIS PART UNSPECIFIED
MALIGNANT NEOPLASM OF EPIDIDYMIS
MALIGNANT NEOPLASM OF SPERMATIC CORD
MALIGNANT NEOPLASM OF SCROTUM
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
MALE GENITAL ORGANS
187.9
188.0 - 188.9
189.0
189.1
189.2
189.3
189.4
189.8
189.9
MALIGNANT NEOPLASM OF MALE GENITAL ORGAN SITE
UNSPECIFIED
MALIGNANT NEOPLASM OF TRIGONE OF URINARY
BLADDER - MALIGNANT NEOPLASM OF BLADDER PART
UNSPECIFIED
MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS
MALIGNANT NEOPLASM OF RENAL PELVIS
MALIGNANT NEOPLASM OF URETER
MALIGNANT NEOPLASM OF URETHRA
MALIGNANT NEOPLASM OF PARAURETHRAL GLANDS
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
URINARY ORGANS
MALIGNANT NEOPLASM OF URINARY ORGAN SITE
UNSPECIFIED
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
191.0 - 191.9
192.0
192.1
192.2
192.3
192.8
192.9
193
194.0
MALIGNANT NEOPLASM OF EYEBALL EXCEPT
CONJUNCTIVA CORNEA RETINA AND CHOROID MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED
MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES
AND VENTRICLES - MALIGNANT NEOPLASM OF BRAIN
UNSPECIFIED SITE
MALIGNANT NEOPLASM OF CRANIAL NERVES
MALIGNANT NEOPLASM OF CEREBRAL MENINGES
MALIGNANT NEOPLASM OF SPINAL CORD
MALIGNANT NEOPLASM OF SPINAL MENINGES
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF
NERVOUS SYSTEM
MALIGNANT NEOPLASM OF NERVOUS SYSTEM PART
UNSPECIFIED
MALIGNANT NEOPLASM OF THYROID GLAND
MALIGNANT NEOPLASM OF ADRENAL GLAND
194.1
194.3
194.4
194.5
194.6
194.8
194.9
195.0 - 195.5
195.8
196.0
MALIGNANT NEOPLASM OF PARATHYROID GLAND
MALIGNANT NEOPLASM OF PITUITARY GLAND AND
CRANIOPHARYNGEAL DUCT
MALIGNANT NEOPLASM OF PINEAL GLAND
MALIGNANT NEOPLASM OF CAROTID BODY
MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER
PARAGANGLIA
MALIGNANT NEOPLASM OF OTHER ENDOCRINE GLANDS
AND RELATED STRUCTURES
MALIGNANT NEOPLASM OF ENDOCRINE GLAND SITE
UNSPECIFIED
MALIGNANT NEOPLASM OF HEAD FACE AND NECK MALIGNANT NEOPLASM OF LOWER LIMB
MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM
OF LYMPH NODES OF HEAD FACE AND NECK
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
196.2
196.3
196.5
196.6
196.8
196.9
197.0
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM
OF INTRATHORACIC LYMPH NODES
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM
OF INTRA-ABDOMINAL LYMPH NODES
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM
OF LYMPH NODES OF AXILLA AND UPPER LIMB
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM
OF LYMPH NODES OF INGUINAL REGION AND LOWER
LIMB
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM
OF INTRAPELVIC LYMPH NODES
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM
OF LYMPH NODES OF MULTIPLE SITES
SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM
OF LYMPH NODES SITE UNSPECIFIED
SECONDARY MALIGNANT NEOPLASM OF LUNG
197.1
197.2
197.3
197.4
197.5
197.6
198.0 - 198.7
198.81
198.82
SECONDARY MALIGNANT NEOPLASM OF MEDIASTINUM
SECONDARY MALIGNANT NEOPLASM OF PLEURA
SECONDARY MALIGNANT NEOPLASM OF OTHER
RESPIRATORY ORGANS
SECONDARY MALIGNANT NEOPLASM OF SMALL
INTESTINE INCLUDING DUODENUM
SECONDARY MALIGNANT NEOPLASM OF LARGE
INTESTINE AND RECTUM
SECONDARY MALIGNANT NEOPLASM OF
RETROPERITONEUM AND PERITONEUM
SECONDARY MALIGNANT NEOPLASM OF KIDNEY SECONDARY MALIGNANT NEOPLASM OF ADRENAL
GLAND
SECONDARY MALIGNANT NEOPLASM OF BREAST
SECONDARY MALIGNANT NEOPLASM OF GENITAL
ORGANS
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy – TX
Flow Cytometry (L33526) (Page 12 of 22)
Data Source: www.cms.gov
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
199.0
199.1
200.00 - 200.08
200.10 - 200.18
200.20 - 200.28
200.30 - 200.38
SECONDARY MALIGNANT NEOPLASM OF OTHER
SPECIFIED SITES
DISSEMINATED MALIGNANT NEOPLASM
OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE
RETICULOSARCOMA UNSPECIFIED SITE RETICULOSARCOMA INVOLVING LYMPH NODES OF
MULTIPLE SITES
LYMPHOSARCOMA UNSPECIFIED SITE LYMPHOSARCOMA INVOLVING LYMPH NODES OF
MULTIPLE SITES
BURKITT'S TUMOR OR LYMPHOMA UNSPECIFIED SITE BURKITT'S TUMOR OR LYMPHOMA INVOLVING LYMPH
NODES OF MULTIPLE SITES
MARGINAL ZONE LYMPHOMA, UNSPECIFIED SITE,
EXTRANODAL AND SOLID ORGAN SITES - MARGINAL
ZONE LYMPHOMA, LYMPH NODES OF MULTIPLE SITES
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy – TX
Flow Cytometry (L33526) (Page 13 of 22)
Data Source: www.cms.gov
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy – TX
Flow Cytometry (L33526) (Page 14 of 22)
Data Source: www.cms.gov
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy – TX
Flow Cytometry (L33526) (Page 15 of 22)
Data Source: www.cms.gov
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy – TX
Flow Cytometry (L33526) (Page 16 of 22)
Data Source: www.cms.gov
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy – TX
Flow Cytometry (L33526) (Page 17 of 22)
Data Source: www.cms.gov
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
238.1
NEOPLASM OF UNCERTAIN BEHAVIOR OF BLADDER
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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
282.40
282.43
282.44
282.45
282.46
282.47
282.5
282.60 - 282.64
282.68
282.69
282.7
283.2
283.9
HEREDITARY ELLIPTOCYTOSIS
THALASSEMIA, UNSPECIFIED
ALPHA THALASSEMIA
BETA THALASSEMIA
DELTA-BETA THALASSEMIA
THALASSEMIA MINOR
HEMOGLOBIN E-BETA THALASSEMIA
SICKLE-CELL TRAIT
SICKLE-CELL DISEASE UNSPECIFIED - SICKLE-CELL/HB
C DISEASE WITH CRISIS
OTHER SICKLE-CELL DISEASE WITHOUT CRISIS
OTHER SICKLE-CELL DISEASE WITH CRISIS
OTHER HEMOGLOBINOPATHIES
HEMOGLOBINURIA DUE TO HEMOLYSIS FROM
EXTERNAL CAUSES
ACQUIRED HEMOLYTIC ANEMIA UNSPECIFIED
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy – TX
Flow Cytometry (L33526) (Page 20 of 22)
Data Source: www.cms.gov
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
284.09
284.11
284.12
284.19
284.2
284.81
284.89
284.9
285.0
285.22
285.8 - 285.9
287.1
CONSTITUTIONAL RED BLOOD CELL APLASIA
OTHER CONSTITUTIONAL APLASTIC ANEMIA
ANTINEOPLASTIC CHEMOTHERAPY INDUCED
PANCYTOPENIA
OTHER DRUG INDUCED PANCYTOPENIA
OTHER PANCYTOPENIA
MYELOPHTHISIS
RED CELL APLASIA (ACQUIRED) (ADULT) (WITH
THYMOMA)
OTHER SPECIFIED APLASTIC ANEMIAS
APLASTIC ANEMIA UNSPECIFIED
SIDEROBLASTIC ANEMIA
ANEMIA IN NEOPLASTIC DISEASE
OTHER SPECIFIED ANEMIAS - ANEMIA UNSPECIFIED
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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 BLOODFORMING 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
696.0
714.30
HYDATIDIFORM MOLE
PSORIATIC ARTHROPATHY
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy – TX
Flow Cytometry (L33526) (Page 22 of 22)
Data Source: www.cms.gov
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
V42.0 - V42.7
PERSONAL HISTORY OF OTHER LEUKEMIA
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
L32731 Frequency of Laboratory Tests – Glucose Testing
Data Source: www.cms.gov
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
05/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy – TX
L32731 Frequency of Laboratory Tests - Lipids
Data Source: www.cms.gov
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
05/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
L32731 Frequency of Laboratory Tests – Thyroid Testing
Data Source: www.cms.gov
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
05/01/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy - TX
L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (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
076.9
077.0
077.98 - 077.99
098.0
098.10 - 098.17
098.19
098.2
098.30 - 098.37
098.39
098.40 - 098.43
098.49
098.50 - 098.53
098.59
Trachoma Initial Stage - Trachoma Active Stage
Trachoma Unspecified
Inclusion Conjunctivitis
Unspecified Diseases Of Conjunctiva Due To Chlamydiae - Unspecified Diseases Of Conjunctiva Due
To Viruses
Gonococcal Infection (Acute) Of Lower Genitourinary Tract
Gonococcal Infection (Acute) Of Upper Genitourinary Tract Site Unspecified - Gonococcal Salpingitis
Specified As Acute
Other Gonococcal Infection (Acute) Of Upper Genitourinary Tract
Gonococcal Infection Chronic Of Lower Genitourinary Tract
Chronic Gonococcal Infection Of Upper Genitourinary Tract Site Unspecified - Gonococcal Salpingitis (Chronic)
Other Chronic Gonococcal Infection Of Upper Genitourinary Tract
Gonococcal Conjunctivitis (Neonatorum) - Gonococcal Keratitis
Other Gonococcal Infection Of Eye
Gonococcal Arthritis - Gonococcal Spondylitis
Other Gonococcal Infection Of Joint
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
12/05/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy - TX
L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (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
098.81 - 098.86
098.89
099.1
099.3
099.41
099.50 - 099.56
Gonococcal Infection Of Pharynx - Gonococcal Infection Of Anus And Rectum
Gonococcal Keratosis (Blennorrhagica) - Gonococcal Peritonitis
Gonococcal Infection Of Other Specified Sites
Lymphogranuloma Venereum
Reiter's Disease
Other Nongonococcal Urethritis Chlamydia Trachomatis
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
12/05/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy - TX
L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (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
289.53
289.83
372.00
372.02 - 372.03
372.10 - 372.12
595.4
597.80 - 597.81
601.0
601.8 - 601.9
604.0
604.90 - 604.91
608.89
614.0
614.2 - 614.4
614.6
Chronic Lymphadenitis
Neutropenic Splenomegaly
Myelofibrosis
Acute Conjunctivitis Unspecified
Acute Follicular Conjunctivitis - Other Mucopurulent Conjunctivitis
Chronic Conjunctivitis Unspecified - Chronic Follicular Conjunctivitis
Cystitis In Diseases Classified Elsewhere
Urethritis Unspecified - Urethral Syndrome Nos
Acute Prostatitis
Other Specified Inflammatory Diseases Of Prostate - Prostatitis Unspecified
Orchitis Epididymitis And Epididymo-Orchitis With Abscess
Orchitis And Epididymitis Unspecified - Orchitis And Epididymitis In Diseases Classified Elsewhere
Other Specified Disorders Of Male Genital Organs
Acute Salpingitis And Oophoritis
Salpingitis And Oophoritis Not Specified As Acute Subacute Or Chronic - Chronic Or Unspecified Parametritis And Pelvic Cellulitis
Pelvic Peritoneal Adhesions Female (Postoperative) (Postinfection)
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
12/05/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy - TX
L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (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
616.0
616.10
616.11
616.2
616.3
616.4
616.50
616.51
616.81
616.89
616.9
628.2
629.89
683
Other Specified Inflammatory Disease Of Female Pelvic Organs And Tissues - Unspecified Inflammatory Disease Of Female Pelvic
Organs And Tissues
Cervicitis And Endocervicitis
Vaginitis And Vulvovaginitis Unspecified
Vaginitis And Vulvovaginitis In Diseases Classified Elsewhere
Cyst Of Bartholin's Gland
Abscess Of Bartholin's Gland
Other Abscess Of Vulva
Ulceration Of Vulva Unspecified
Ulceration Of Vulva In Diseases Classified Elsewhere
Mucositis (Ulcerative) Of Cervix, Vagina, And Vulva
Other Inflammatory Disease Of Cervix, Vagina And Vulva
Unspecified Inflammatory Disease Of Cervix Vagina And Vulva
Infertility Female Of Tubal Origin
Other Specified Disorders Of Female Genital Organs
Acute Lymphadenitis
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
12/05/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (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
716.50 - 716.59
716.60 - 716.68
716.90 - 716.99
719.40 - 719.49
727.00
727.05 - 727.06
727.09
771.6
780.60 - 780.61
782.1
785.6
788.1
788.64 - 788.65
788.7
789.00 - 789.07
Unspecified Infective Arthritis Site Unspecified - Unspecified Infective Arthritis Involving Multiple Sites
Unspecified Polyarthropathy Or Polyarthritis Site Unspecified - Unspecified Polyarthropathy Or Polyarthritis Involving Multiple Sites
Unspecified Monoarthritis Site Unspecified - Unspecified Monoarthritis Involving Other Specified Sites
Unspecified Arthropathy Site Unspecified - Unspecified Arthropathy Involving Multiple Sites
Pain In Joint Site Unspecified - Pain In Joint Involving Multiple Sites
Synovitis And Tenosynovitis Unspecified
Other Tenosynovitis Of Hand And Wrist - Tenosynovitis Of Foot And Ankle
Other Synovitis And Tenosynovitis
Neonatal Conjunctivitis And Dacryocystitis
Fever, Unspecified - Fever Presenting With Conditions Classified Elsewhere
Rash And Other Nonspecific Skin Eruption
Enlargement Of Lymph Nodes
Dysuria
Urinary Hesitancy - Straining On Urination
Urethral Discharge
Abdominal Pain Unspecified Site - Abdominal Pain Generalized
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
12/05/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
L33644 – Molecular Diagnostics: Genitourinary Infectious Disease Testing (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
716.50 - 716.59
716.60 - 716.68
716.90 - 716.99
719.40 - 719.49
727.00
727.05 - 727.06
727.09
771.6
780.60 - 780.61
782.1
785.6
788.1
788.64 - 788.65
788.7
789.00 - 789.07
Unspecified Infective Arthritis Site Unspecified - Unspecified Infective Arthritis Involving Multiple Sites
Unspecified Polyarthropathy Or Polyarthritis Site Unspecified - Unspecified Polyarthropathy Or Polyarthritis Involving Multiple Sites
Unspecified Monoarthritis Site Unspecified - Unspecified Monoarthritis Involving Other Specified Sites
Unspecified Arthropathy Site Unspecified - Unspecified Arthropathy Involving Multiple Sites
Pain In Joint Site Unspecified - Pain In Joint Involving Multiple Sites
Synovitis And Tenosynovitis Unspecified
Other Tenosynovitis Of Hand And Wrist - Tenosynovitis Of Foot And Ankle
Other Synovitis And Tenosynovitis
Neonatal Conjunctivitis And Dacryocystitis
Fever, Unspecified - Fever Presenting With Conditions Classified Elsewhere
Rash And Other Nonspecific Skin Eruption
Enlargement Of Lymph Nodes
Dysuria
Urinary Hesitancy - Straining On Urination
Urethral Discharge
Abdominal Pain Unspecified Site - Abdominal Pain Generalized
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
12/05/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Data Source: www.cms.gov
Medicare Local Coverage Determination Policy – TX
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.
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
12/05/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
L34352 Qualitative Drug Screening (Page 1 of 2)
Data Source: www.cms.gov
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
295.00
295.10
295.20
295.30
304.01
304.90
305.90
345.10
345.11
345.3
345.90
345.91
426.10
426.11
426.12
426.13
426.82
Acidosis
Simple Type Schizophrenia Unspecified State
Disorganized Type Schizophrenia Unspecified State
Catatonic Type Schizophrenia Unspecified State
Paranoid Type Schizophrenia Unspecified State
Opioid Type Dependence Continuous Use
Unspecified Drug Dependence Unspecified Use
Other Mixed Or Unspecified Drug Abuse Unspecified Use
Generalized Convulsive Epilepsy Without Intractable
Epilepsy
Generalized Convulsive Epilepsy With Intractable Epilepsy
Grand Mal Status Epileptic
Epilepsy Unspecified Without Intractable Epilepsy
Epilepsy Unspecified With Intractable Epilepsy
Atrioventricular Block Unspecified
First Degree Atrioventricular Block
Mobitz (Type) Ii Atrioventricular Block
Other Second Degree Atrioventricular Block
Long Qt Syndrome
427.0
427.1
780.01
780.09
780.1
780.39
780.97
963.0
965.00
965.01
965.02
965.09
965.1
965.4
965.5
965.61
966.1
967.0
Paroxysmal Supraventricular Tachycardia
Paroxysmal Ventricular Tachycardia
Coma
Alteration Of Consciousness Other
Hallucinations
Other Convulsions
Altered Mental Status
Poisoning By Antiallergic And Antiemetic Drugs
Poisoning By Opium (Alkaloids) Unspecified
Poisoning By Heroin
Poisoning By Methadone
Poisoning By Other Opiates And Related Narcotics
Poisoning By Salicylates
Poisoning By Aromatic Analgesics Not Elsewhere Classified
Poisoning By Pyrazole Derivatives
Poisoning By Propionic Acid Derivatives
Poisoning By Hydantoin Derivatives
Poisoning By Barbiturates
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/25/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy - TX
L34352 Qualitative Drug Screening (Page 2 of 2)
Data Source: www.cms.gov
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
967.2
967.2
967.3
967.4
967.5
967.6
967.8
967.9
969.00
969.01
969.02
969.03
969.04
969.05
969.09
969.1
969.2
Poisoning By Chloral Hydrate Group
Poisoning By Paraldehyde
Poisoning By Paraldehyde
Poisoning By Bromine Compounds
Poisoning By Methaqualone Compounds
Poisoning By Glutethimide Group
Poisoning By Mixed Sedatives Not Elsewhere Classified
Poisoning By Other Sedatives And Hypnotics
Poisoning By Unspecified Sedative Or Hypnotic
Poisoning By Antidepressant, Unspecified
Poisoning By Monoamine Oxidase Inhibitors
Poisoning By Selective Serotonin And Norepinephrine
Reuptake Inhibitors
Poisoning By Selective Serotonin Reuptake Inhibitors
Poisoning By Tetracyclic Antidepressants
Poisoning By Tricyclic Antidepressants
Poisoning By Other Antidepressants
Poisoning By Phenothiazine-Based Tranquilizers
Poisoning By Butyrophenone-Based Tranquilizers
969.3
969.4
969.5
969.6
969.70
969.71
969.72
969.73
969.79
969.8
969.9
970.81
970.89
972.1
977.9
V15.81
V58.69
Poisoning By Other Antipsychotics Neuroleptics
And Major Tranquilizers
Poisoning By Benzodiazepine-Based Tranquilizers
Poisoning By Other Tranquilizers
Poisoning By Psychodysleptics (Hallucinogens)
Poisoning By Psychostimulant, Unspecified
Poisoning By Caffeine
Poisoning By Amphetamines
Poisoning By Methylphenidate
Poisoning By Other Psychostimulants
Poisoning By Other Specified Psychotropic Agents
Poisoning By Unspecified Psychotropic Agent
Poisoning By Cocaine
Poisoning By Other Central Nervous System Stimulants
Poisoning By Cardiotonic Glycosides And Drugs Of Similar Action
Poisoning By Unspecified Drug Or Medicinal Substance
Personal History Of Noncompliance With Medical Treatment
Presenting Hazards To Health
Long-Term (Current) Use Of Other Medications
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/25/13
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved
Medicare Local Coverage Determination Policy – TX
L31686 Services That Are Not Reasonable and Necessary
Data Source: www.cms.gov
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
This list was compiled from Medicare’s Limited Coverage Policies for informational and reference purposes only. For the most current information please reference www.cms.gov.
Note: If the patient’s medical record does not support one of the above ICD-9-CM codes, please prepare an Advance Beneficiary Notice form, and ask the patient to read and sign it.
Source: Federal Registry Negotiated Rule-making, November 23, 2001
“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.”
Last Updated:
Quest, Quest Diagnostics, any associated logos, and all associated Quest Diagnostics registered or unregistered trademarks are the property of Quest Diagnostics.
03/17/15
All third party marks - ® and ™ - are the property of their respective owners. © 2015 Quest Diagnostics Incorporated. All rights reserved