Medicare Contractor Changing from Noridian or WPS to National Government Services:

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1 Medicare Contractor Changing from Noridian or WPS to National Government Services: Minnesota and Wisconsin are moving to the new J6 Regional Medicare Contractor. Part A Services will convert effective August 10 th and Part B Services will convert effective September 10 th. Part of the conversion will include Local Coverage Policies that impact laboratory testing. A summary of the new Coverage Policies are detailed below. These policies are in conjunction with the National Coverage Policies (NCD) that remain in effect. HML Policy Changes will go into effect on August 10, 2013! LCD for Galectin-3 (L32977) Review of the literature suggests that at some point this assay may be found useful in the management of congestive heart failure. Presently, National Government Services considers this assay for CHF patients and similar assays related to the elaboration of galectin-3 protein to be of an uncertain role in the clinical management of patients. Consequently, it is considered not covered for all indications. CPT/HCPCS Codes GALECTIN-3 LCD for Combined Ovarian Cancer Biomarker Tests (L32589) At the present time, National Government Services does not find either the OVA-1 or the ROMA test to be of proven efficacy in the diagnosis or treatment of ovarian cancer. National Government Services will only allow coverage of CA-125 as allowed by the national coverage decision. CPT/HCPCS Codes UNLISTED CHEMISTRY PROCEDURE LCD for B-type Natriuretic Peptide (BNP) Testing (L26375 BNP measurements must be analyzed in conjunction with standard diagnostic tests, medical history and clinical findings. The efficacy of BNP measurement as a stand-alone test has not yet been established. Clinicians should be aware that certain conditions such as ischemia, infarction and renal insufficiency, may cause elevation of circulating BNP concentration and require alterations of the interpretation of BNP results. Additional investigation is required to further define the diagnostic value of plasma BNP in monitoring the efficiency of treatment for CHF and in tailoring the therapy for heart failure. Therefore, BNP measurements for monitoring and management of CHF are not a covered service. Although a correlation between serum BNP levels and the clinical severity of HF has been shown in broad populations, it cannot be assumed that BNP levels can be used effectively as targets for adjustment of therapy in individual patients. [T]he BNP measurement has not been clearly shown to supplement careful clinical

2 assessment. (Hunt SA, Abraham WT, Chin MH, et al. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, pgs ) CPT/HCPCS Codes NATRIURETIC PEPTIDE ICD-9-CM codes that support medical necessity when billed in either an office or outpatient setting MALIGNANT HYPERTENSIVE HEART DISEASE WITH HEART FAILURE BENIGN HYPERTENSIVE HEART DISEASE WITH HEART FAILURE UNSPECIFIED HYPERTENSIVE HEART DISEASE WITH HEART FAILURE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE CONGESTIVE HEART FAILURE UNSPECIFIED LEFT HEART FAILURE UNSPECIFIED SYSTOLIC HEART FAILURE ACUTE SYSTOLIC HEART FAILURE CHRONIC SYSTOLIC HEART FAILURE ACUTE ON CHRONIC SYSTOLIC HEART FAILURE UNSPECIFIED DIASTOLIC HEART FAILURE ACUTE DIASTOLIC HEART FAILURE CHRONIC DIASTOLIC HEART FAILURE ACUTE ON CHRONIC DIASTOLIC HEART FAILURE UNSPECIFIED COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE ACUTE COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE ACUTE ON CHRONIC COMBINED SYSTOLIC AND DIASTOLIC HEART FAILURE HEART FAILURE UNSPECIFIED

3 OBSTRUCTIVE CHRONIC BRONCHITIS WITH (ACUTE) EXACERBATION OBSTRUCTIVE CHRONIC BRONCHITIS WITH ACUTE BRONCHITIS CHRONIC OBSTRUCTIVE ASTHMA WITH (ACUTE) EXACERBATION ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION ACUTE BRONCHOSPASM RESPIRATORY ABNORMALITY UNSPECIFIED ORTHOPNEA SHORTNESS OF BREATH TACHYPNEA WHEEZING RESPIRATORY ABNORMALITY OTHER LCD for Vitamin D Assay Testing (L29510) For Medicare beneficiaries, screening tests are governed by statute. Vitamin D testing may not be used for routine screening. Once a beneficiary has been shown to be vitamin D 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. CPT/HCPCS Codes VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED ICD-9 Codes that Support Medical Necessity HYPERPARATHYROIDISM, UNSPECIFIED PRIMARY HYPERPARATHYROIDISM 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) CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V

4 585.6 END STAGE RENAL DISEASE SECONDARY HYPERPARATHYROIDISM (OF RENAL ORIGIN) OSTEOPOROSIS UNSPECIFIED SENILE OSTEOPOROSIS IDIOPATHIC OSTEOPOROSIS DISUSE OSTEOPOROSIS OTHER OSTEOPOROSIS DISORDER OF BONE AND CARTILAGE UNSPECIFIED LCD for Qualitative Drug Screening (L28145) A qualitative drug screen is not medically reasonable or necessary to screen for the same drug with both a blood and a urine specimen simultaneously. Medicare regards 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) as not medically necessary. CPT/HCPCS Codes DRUG CONFIRMATION, EACH PROCEDURE G0431 G0434 DRUG SCREEN, QUALITATIVE; MULTIPLE DRUG CLASSES BY HIGH COMPLEXITY TEST METHOD (E.G., IMMUNOASSAY, ENZYME ASSAY), PER PATIENT ENCOUNTER DRUG SCREEN, OTHER THAN CHROMATOGRAPHIC; ANY NUMBER OF DRUG CLASSES, BY CLIA WAIVED TEST OR MODERATE COMPLEXITY TEST, PER PATIENT ENCOUNTER ICD-9 Codes that Support Medical Necessity ACIDOSIS OPIOID TYPE DEPENDENCE UNSPECIFIED USE OPIOID TYPE DEPENDENCE CONTINUOUS USE OPIOID TYPE DEPENDENCE EPISODIC USE OPIOID TYPE DEPENDENCE IN REMISSION SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, CONTINUOUS SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, EPISODIC SEDATIVE, HYPNOTIC OR ANXIOLYTIC DEPENDENCE, IN REMISSION COCAINE DEPENDENCE UNSPECIFIED USE COCAINE DEPENDENCE CONTINUOUS USE COCAINE DEPENDENCE EPISODIC USE COCAINE DEPENDENCE IN REMISSION CANNABIS DEPENDENCE UNSPECIFIED USE CANNABIS DEPENDENCE CONTINUOUS USE CANNABIS DEPENDENCE EPISODIC USE CANNABIS DEPENDENCE IN REMISSION

5 AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE UNSPECIFIED USE AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE CONTINUOUS USE AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE EPISODIC USE AMPHETAMINE AND OTHER PSYCHOSTIMULANT DEPENDENCE IN REMISSION HALLUCINOGEN DEPENDENCE UNSPECIFIED USE HALLUCINOGEN DEPENDENCE CONTINUOUS USE HALLUCINOGEN DEPENDENCE EPISODIC USE HALLUCINOGEN DEPENDENCE IN REMISSION OTHER SPECIFIED DRUG DEPENDENCE UNSPECIFIED USE OTHER SPECIFIED DRUG DEPENDENCE CONTINUOUS USE OTHER SPECIFIED DRUG DEPENDENCE EPISODIC USE OTHER SPECIFIED DRUG DEPENDENCE IN REMISSION COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG DEPENDENCE UNSPECIFIED USE COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG DEPENDENCE CONTINUOUS USE COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG DEPENDENCE EPISODIC USE COMBINATIONS OF OPIOID TYPE DRUG WITH ANY OTHER DRUG DEPENDENCE IN REMISSION COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID TYPE DRUG UNSPECIFIED USE COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID TYPE DRUG CONTINUOUS US COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID TYPE DRUG EPISODIC USE COMBINATIONS OF DRUG DEPENDENCE EXCLUDING OPIOID TYPE DRUG IN REMISSION UNSPECIFIED DRUG DEPENDENCE UNSPECIFIED USE UNSPECIFIED DRUG DEPENDENCE CONTINUOUS USE UNSPECIFIED DRUG DEPENDENCE EPISODIC USE UNSPECIFIED DRUG DEPENDENCE IN REMISSION NONDEPENDENT ALCOHOL ABUSE UNSPECIFIED DRINKING BEHAVIOR NONDEPENDENT ALCOHOL ABUSE CONTINUOUS DRINKING BEHAVIOR NONDEPENDENT ALCOHOL ABUSE EPISODIC DRINKING BEHAVIOR NONDEPENDENT ALCOHOL ABUSE IN REMISSION NONDEPENDENT CANNABIS ABUSE UNSPECIFIED USE NONDEPENDENT CANNABIS ABUSE CONTINUOUS USE NONDEPENDENT CANNABIS ABUSE EPISODIC USE NONDEPENDENT CANNABIS ABUSE IN REMISSION NONDEPENDENT HALLUCINOGEN ABUSE UNSPECIFIED USE NONDEPENDENT HALLUCINOGEN ABUSE CONTINUOUS USE NONDEPENDENT HALLUCINOGEN ABUSE EPISODIC USE NONDEPENDENT HALLUCINOGEN ABUSE IN REMISSION SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, UNSPECIFIED SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, CONTINUOUS SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, EPISODIC SEDATIVE, HYPNOTIC OR ANXIOLYTIC ABUSE, IN REMISSION NONDEPENDENT OPIOID ABUSE UNSPECIFIED USE NONDEPENDENT OPIOID ABUSE CONTINUOUS USE

6 NONDEPENDENT OPIOID ABUSE EPISODIC USE NONDEPENDENT OPIOID ABUSE IN REMISSION NONDEPENDENT COCAINE ABUSE UNSPECIFIED USE NONDEPENDENT COCAINE ABUSE CONTINUOUS USE NONDEPENDENT COCAINE ABUSE EPISODIC USE NONDEPENDENT COCAINE ABUSE IN REMISSION NONDEPENDENT AMPHETAMINE OR RELATED ACTING SYMPATHOMIMETIC ABUSE UNSPECIFIED USE NONDEPENDENT AMPHETAMINE OR RELATED ACTING SYMPATHOMIMETIC ABUSE CONTINUOUS USE NONDEPENDENT AMPHETAMINE OR RELATED ACTING SYMPATHOMIMETIC ABUSE EPISODIC USE NONDEPENDENT AMPHETAMINE OR RELATED ACTING SYMPATHOMIMETIC ABUSE IN REMISSION NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE UNSPECIFIED USE NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE CONTINUOUS USE NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE EPISODIC USE NONDEPENDENT ANTIDEPRESSANT TYPE ABUSE EPISODIC USE OTHER MIXED OR UNSPECIFIED DRUG ABUSE UNSPECIFIED USE NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE CONTINUOUS USE NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE EPISODIC USE NONDEPENDENT OTHER MIXED OR UNSPECIFIED DRUG ABUSE IN REMISSION 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 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

7 965.5 POISONING BY PYRAZOLE DERIVATIVES POISONING BY PROPIONIC ACID DERIVATIVES POISONING BY HYDANTOIN DERIVATIVES POISONING BY BARBITURATES POISONING BY CHLORAL HYDRATE GROUP 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 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 V15.81 PERSONAL HISTORYOF NONCOMPLIANCE WITH MEDICAL TREATMENT PRESENTING HAZARDS TO HEALTH V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS V71.09 OBSERVATION OF OTHER SUSPECTED MENTAL CONDITION LCD for RAST Type Tests (L28463)

8 CPT/HCPCS Codes (Note: CPT codes and are not covered services) ALLERGEN SPECIFIC IGG QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN ALLERGEN SPECIFIC IGE; QUANTITATIVE OR SEMIQUANTITATIVE, EACH ALLERGEN ALLERGEN SPECIFIC IGE; QUALITATIVE, MULTIALLERGEN SCREEN (DIPSTICK, PADDLE, OR DISK) ICD-9 Codes that Support Medical Necessity - The following ICD-9 Codes apply only to CPT code 86003: ALLERGIC RHINITIS DUE TO POLLEN ALLERGIC RHINITIS DUE TO FOOD ALLERGIC RHINITIS, DUE TO ANIMAL (CAT) (DOG) HAIR AND DANDER ALLERGIC RHINITIS DUE TO OTHER ALLERGEN ALLERGIC RHINITIS CAUSE UNSPECIFIED EXTRINSIC ASTHMA UNSPECIFIED EXTRINSIC ASTHMA WITH STATUS ASTHMATICUS EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION COUGH VARIANT ASTHMA ASTHMA UNSPECIFIED ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION OTHER ATOPIC DERMATITIS AND RELATED CONDITIONS ALLERGIC URTICARIA OTHER SPECIFIED URTICARIA UNSPECIFIED URTICARIA WHEEZING 989.5* TOXIC EFFECT OF VENOM OTHER ANAPHYLACTIC REACTION ANGIONEUROTIC EDEMA NOT ELSEWHERE CLASSIFIED UNSPECIFIED ADVERSE EFFECT OF UNSPECIFIED DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE UNSPECIFIED ADVERSE EFFECT OF ANESTHESIA OTHER DRUG ALLERGY UNSPECIFIED ADVERSE EFFECT OF OTHER DRUG, MEDICINAL AND BIOLOGICAL SUBSTANCE ALLERGY UNSPECIFIED NOT ELSEWHERE CLASSIFIED ANAPHYLACTIC REACTION DUE TO UNSPECIFIED FOOD ANAPHYLACTIC REACTION DUE TO PEANUTS ANAPHYLACTIC REACTION DUE TO CRUSTACEANS

9 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 V15.09 PERSONAL HISTORY OF OTHER ALLERGY OTHER THAN TO MEDICINAL AGENTS LCD for Heavy Metal Testing (L33384) The term heavy metal testing is historically used to describe elements such as lead, arsenic, mercury, cadmium, and chromium. In general, all of the heavy metals in inorganic form cause GI irritation, resulting in nausea, vomiting, abdominal pain and diarrhea. The next most consistent toxicity for the heavy metals as a group, but not for every heavy metal, is renal toxicity. A further generalization is that each member of the heavy metal group tends to cause multi-organ toxicity. Many metals cause cutaneous abnormalities, such as irritant and allergic contact dermatitis, urticaria, keratoses, and premalignant and malignant lesions. Several of the heavy metals produce central and peripheral nervous system toxicity. Other metals cause pulmonary illness. However, before any testing for heavy metal is ordered, a detailed medical history of the patient must be obtained, including a careful documentation of occupational and avocational exposure to these toxins. A complete physical examination must be done. 1. Aluminum. Serum aluminum testing is payable for beneficiaries who have been on dialysis with evidence suggesting aluminum toxicity, or for beneficiaries with chronic industrial exposure history 2. Antimony. Serum and/or urine antimony testing is payable for beneficiaries with documented treatment in the past with antileishmaniasis agents or with documented chronic antimony industrial exposure history. 3. Arsenic. Serum and whole blood and/or urine arsenic testing is payable for beneficiaries with unexplained peripheral neuropathies, industrial exposure to arsenic, histories of arsenic pesticide exposure, unexplained encephalopathies, unexplained weight loss, chronic glomerulonephritis, bone marrow hypoplasia, or melanosis of skin, unexplained chronic diarrhea, persistent abdominal pain, or nausea and vomiting. 4. Barium. Serum and or/urine barium testing is payable for beneficiaries with pulmonary disease with industrial exposure to barium or unexplained flaccid paralysis. 5. Beryllium. Serum and/or urine beryllium testing is payable for beneficiaries with pulmonary disease with industrial exposure to beryllium. 6. Bismuth. Serum and/or urine bismuth testing is payable for beneficiaries with bismuth lines on their gums, methemoglobinemia, unexplained pathological fractures, or a history of bismuth medicine abuse. 7. Cadmium. Serum and whole blood and/or urine cadmium testing is payable for beneficiaries with an exposure to cadmium with evidence of pulmonary disease or unexplained renal failure. 8. Chromium. Serum chromium testing is payable for beneficiaries with an industrial exposure to chromium with evidence of pulmonary disease.

10 9. Cobalt. Serum cobalt testing is payable for beneficiaries with an industrial exposure to cobalt with evidence of pulmonary disease 10. Copper. Serum copper testing is payable for beneficiaries with an industrial exposure to copper with evidence of pulmonary disease, or for beneficiaries with Wilson's Disease, unexplained cardiomyopathy, unexplained renal failure, polycythemia. unexplained myelodysplastic syndrome or known ingestion of zinc. 11. Iron. See the Laboratory National Coverage Determinations (NCDs) Database. 12. Lead. Blood (serum and whole) and/or urine lead testing is covered if there is documented industrial exposure to lead, documented avocation exposure to lead, retained bullet fragments at or near joints, a blue gum line, a history of moonshine abuse, unexplained peripheral neuropathies, evidence of lead contaminated drinking water, paint stripping, lead lines on bones on radiographs, or basophilic stippling of red blood cells. 13. Lithium. Serum and/or urine lithium testing is covered for beneficiaries on lithium medications. 14. Manganese. Serum manganese testing is covered for beneficiaries with documented industrial exposure to manganese. 15. Mercury. Serum, whole blood, and/or urine mercury testing is covered for beneficiaries with documented industrial exposure to mercury, with a blue line in their mouth, those with a history of laxative abuse, with a history of pesticide exposure, mercury spillage with vacuuming of the liquid metal, unexplained renal failure, or a history of skin lightening treatments. 16. Molybdenum. Serum molybdenum testing is covered for beneficiaries with documented industrial exposure to molybdenum. 17. Nickel. Serum and/or urine nickel testing is covered for beneficiaries with documented industrial exposure to nickel, unexplained renal failure, unexplained pulmonary disease. 18. Selenium. Serum and/or urine selenium testing is covered for beneficiaries with documented industrial exposure to selenium or on chronic renal dialysis. 19. Thallium. Serum thallium testing is covered for beneficiaries with documented industrial exposure to thallium and unexplained ataxia. 20. Tin. Serum tin testing is covered for beneficiaries with documented industrial exposure to tin. 21. Titanium. Serum titanium testing is covered for beneficiaries with documented industrial exposure to titanium. 22. Zinc. Serum zinc and/or urine testing is covered for beneficiaries with documented industrial exposure to zinc, on chronic renal dialysis, with malabsorption syndromes, Crohn's disease, unexplained myelodysplastic syndrome or known ingestion of zinc. Documented recent, long-term total parenteral nutrition (TPN) with clinical trace element deficiency evidence is acceptable medical indications for testing for copper, manganese, and zinc. CPT/HCPCS Codes LITHIUM

11 82108 ALUMINUM ARSENIC CADMIUM CHROMIUM COPPER HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); SCREEN HEAVY METAL (EG, ARSENIC, BARIUM, BERYLLIUM, BISMUTH, ANTIMONY, MERCURY); QUANTITATIVE, EACH IRON LEAD MANGANESE MERCURY, QUANTITATIVE NICKEL SELENIUM SILICA ZINC UNLISTED CHEMISTRY PROCEDURE ICD-9 Codes that Support Medical Necessity Aluminum - Group 1: Codes PATHOLOGICAL DRUG INTOXICATION DRUG-INDUCED DELIRIUM DRUG-INDUCED PERSISTING DEMENTIA DRUG-INDUCED PERSISTING AMNESTIC DISORDER DRUG-INDUCED MOOD DISORDER OTHER SPECIFIED DRUG-INDUCED MENTAL DISORDERS UNSPECIFIED TRANSIENT MENTAL DISORDER IN CONDITIONS CLASSIFIED ELSEWHERE OTHER PERSISTENT MENTAL DISORDERS DUE TO CONDITIONS CLASSIFIED ELSEWHERE CHRONIC KIDNEY DISEASE, STAGE I - END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, UNSPECIFIED POISONING BY ANTACIDS AND ANTIGASTRIC SECRETION DRUGS OTHER COMPLICATIONS DUE TO RENAL DIALYSIS DEVICE IMPLANT AND GRAFT Antimony - Group 2: Codes

12 085.9 LEISHMANIASIS UNSPECIFIED TOXIC EFFECT OF ANTIMONY AND ITS COMPOUNDS Arsenic - Group 3: Codes OTHER SPECIFIED APLASTIC ANEMIAS ENCEPHALOPATHY UNSPECIFIED METABOLIC ENCEPHALOPATHY OTHER ENCEPHALOPATHY HEREDITARY PERIPHERAL NEUROPATHY UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS OTHER SPECIFIED DISORDERS OF INTESTINES CHRONIC GLOMERULONEPHRITIS WITH UNSPECIFIED PATHOLOGICAL LESION IN KIDNEY CONTACT DERMATITIS AND OTHER ECZEMA DUE TO OTHER CHEMICAL PRODUCTS LOSS OF WEIGHT NAUSEA WITH VOMITING DIARRHEA POISONING BY ARSENICAL ANTI-INFECTIVES TOXIC EFFECT OF ARSENIC AND ITS COMPOUNDS Barium - Group 4: Codes OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED Beryllium - Group 5: Codes OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED TOXIC EFFECT OF BERYLLIUM AND ITS COMPOUNDS Bismuth - Group 6: Codes METHEMOGLOBINEMIA OTHER SPECIFIED PERIODONTAL DISEASES PATHOLOGICAL FRACTURE UNSPECIFIED SITE Cadmium - Group 7: Codes

13 OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED 586 RENAL FAILURE UNSPECIFIED TOXIC EFFECT OF CADMIUM AND ITS COMPOUNDS Chromium - Group 8: Codes OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED TOXIC EFFECT OF CHROMIUM Cobalt - Group 9: Codes OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED Copper - Group 10: Codes LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS - MYELODYSPLASTIC SYNDROME, UNSPECIFIED DISORDERS OF COPPER METABOLISM SECONDARY CARDIOMYOPATHY UNSPECIFIED OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED CHRONIC HEPATITIS UNSPECIFIED CHRONIC PERSISTENT HEPATITIS CIRRHOSIS OF LIVER WITHOUT ALCOHOL UNSPECIFIED CHRONIC LIVER DISEASE WITHOUT ALCOHOL UNSPECIFIED DISORDER OF LIVER 586 RENAL FAILURE UNSPECIFIED OTHER SPECIFIED CONGENITAL ANOMALIES FEEDING DIFFICULTIES AND MISMANAGEMENT OTHER NONSPECIFIC ABNORMAL SERUM ENZYME LEVELS Iron - See Laboratory National Coverage Determinations (NCDs) Database - Group 11: Codes XX000 Not Applicable Lead - Group 12: Codes ENCEPHALOPATHY UNSPECIFIED METABOLIC ENCEPHALOPATHY

14 OTHER ENCEPHALOPATHY OTHER MONONEURITIS OF UPPER LIMB MONONEURITIS OF UPPER LIMB UNSPECIFIED MONONEURITIS OF LOWER LIMB UNSPECIFIED MONONEURITIS OF UNSPECIFIED SITE HEREDITARY PERIPHERAL NEUROPATHY PERONEAL MUSCULAR ATROPHY HEREDITARY SENSORY NEUROPATHY REFSUM'S DISEASE IDIOPATHIC PROGRESSIVE POLYNEUROPATHY OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY PRECIPITOUS DROP IN HEMATOCRIT OTHER ABNORMALITY OF RED BLOOD CELLS NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF MUSCULOSKELETAL SYSTEM TOXIC EFFECT OF INORGANIC LEAD COMPOUNDS TOXIC EFFECT OF ORGANIC LEAD COMPOUNDS TOXIC EFFECT OF OTHER LEAD COMPOUNDS TOXIC EFFECT OF UNSPECIFIED LEAD COMPOUND Lithium - Group 13: Codes BIPOLAR I DISORDER, SINGLE MANIC EPISODE, UNSPECIFIED BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MILD BIPOLAR I DISORDER, SINGLE MANIC EPISODE, MODERATE BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, SINGLE MANIC EPISODE, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN PARTIAL OR UNSPECIFIED REMISSION BIPOLAR I DISORDER, SINGLE MANIC EPISODE, IN FULL REMISSION MANIC AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE MANIC AFFECTIVE DISORDER RECURRENT EPISODE MILD DEGREE MANIC AFFECTIVE DISORDER RECURRENT EPISODE MODERATE DEGREE MANIC AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC

15 BEHAVIOR MANIC AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR MANIC AFFECTIVE DISORDER RECURRENT EPISODE IN PARTIAL OR UNSPECIFIED REMISSION MANIC AFFECTIVE DISORDER RECURRENT EPISODE IN FULL REMISSION MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE UNSPECIFIED DEGREE MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE MILD DEGREE MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE MODERATE DEGREE MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE SEVERE DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN PARTIAL OR UNSPECIFIED REMISSION MAJOR DEPRESSIVE AFFECTIVE DISORDER SINGLE EPISODE IN FULL REMISSION MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE UNSPECIFIED DEGREE MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MILD DEGREE MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE MODERATE DEGREE MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE WITHOUT PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE SEVERE DEGREE SPECIFIED AS WITH PSYCHOTIC BEHAVIOR MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN PARTIAL OR UNSPECIFIED REMISSION MAJOR DEPRESSIVE AFFECTIVE DISORDER RECURRENT EPISODE IN FULL REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, UNSPECIFIED BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, MILD BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, MODERATE BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN PARTIAL OR UNSPECIFIED REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MANIC, IN FULL REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, UNSPECIFIED

16 BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MILD BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, MODERATE BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, IN PARTIAL OR UNSPECIFIED REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) DEPRESSED, IN FULL REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, UNSPECIFIED BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MILD BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, MODERATE BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, WITHOUT MENTION OF PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, SEVERE, SPECIFIED AS WITH PSYCHOTIC BEHAVIOR BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN PARTIAL OR UNSPECIFIED REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) MIXED, IN FULL REMISSION BIPOLAR I DISORDER, MOST RECENT EPISODE (OR CURRENT) UNSPECIFIED BIPOLAR DISORDER, UNSPECIFIED ATYPICAL MANIC DISORDER ATYPICAL DEPRESSIVE DISORDER OTHER AND UNSPECIFIED BIPOLAR DISORDERS, OTHER UNSPECIFIED EPISODIC MOOD DISORDER OTHER SPECIFIED EPISODIC MOOD DISORDER 311 DEPRESSIVE DISORDER NOT ELSEWHERE CLASSIFIED POISONING BY OTHER SPECIFIED PSYCHOTROPIC AGENTS V58.63 LONG-TERM (CURRENT) USE OF ANTIPLATELETS/ANTITHROMBOTICS V58.64 LONG-TERM (CURRENT) USE OF NONSTEROIDAL ANTI-INFLAMMATORIES V58.65 LONG-TERM (CURRENT) USE OF STEROIDS V58.69 LONG-TERM (CURRENT) USE OF OTHER MEDICATIONS V58.83 ENCOUNTER FOR THERAPEUTIC DRUG MONITORING

17 Manganese - Group 14: Codes UNSPECIFIED EXTRAPYRAMIDAL DISEASE AND ABNORMAL MOVEMENT DISORDER OTHER EXTRAPYRAMIDAL DISEASES AND ABNORMAL MOVEMENT DISORDERS FEEDING DIFFICULTIES AND MISMANAGEMENT TOXIC EFFECT OF MANGANESE AND ITS COMPOUNDS Mercury - Group 15: Codes UNSPECIFIED EXTRAPYRAMIDAL DISEASE AND ABNORMAL MOVEMENT DISORDER OTHER EXTRAPYRAMIDAL DISEASES AND ABNORMAL MOVEMENT DISORDERS FRIEDREICH'S ATAXIA OTHER CEREBELLAR ATAXIA CEREBELLAR ATAXIA IN DISEASES CLASSIFIED ELSEWHERE ATAXIA 586 RENAL FAILURE UNSPECIFIED LACK OF COORDINATION POISONING BY HEAVY METAL ANTI-INFECTIVES POISONING BY OTHER CATHARTICS INCLUDING INTESTINAL ATONIA POISONING BY OTHER AGENTS PRIMARILY AFFECTING SKIN AND MUCOUS MEMBRANE TOXIC EFFECT OF MERCURY AND ITS COMPOUNDS Molybdenum - Group 16: Codes Nickel - Group 17: Codes OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED 586 RENAL FAILURE UNSPECIFIED Selenium - Group 18: Codes 586 RENAL FAILURE UNSPECIFIED Thallium - Group 19: Codes POLYNEUROPATHY DUE TO OTHER TOXIC AGENTS LACK OF COORDINATION

18 Tin - Group 20: Codes Titanium - Group 21: Codes Zinc - Group 22: Codes LOW GRADE MYELODYSPLASTIC SYNDROME LESIONS - MYELODYSPLASTIC SYNDROME, UNSPECIFIED REGIONAL ENTERITIS OF UNSPECIFIED SITE UNSPECIFIED INTESTINAL MALABSORPTION 586 RENAL FAILURE UNSPECIFIED FEEDING DIFFICULTIES AND MISMANAGEMENT Group 23: Codes Boron - No covered ICD-9 codes Phosphorous - No covered ICD-9 codes Silica - No covered ICD-9 codes Strontium - No covered ICD-9 codes Sulfur - No covered ICD-9 codes Uranium - No covered ICD-9 codes Vanadium - No covered ICD-9 codes