Clinical Diagnostic Laboratory Services. Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report.

Transcription

1 Medicare National Coverage Determinations (NCD) Coding Policy Manual and Change Report July 2010 Clinical Diagnostic Laboratory Services Health & Human Services Department Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD CMS Point of Contact: TDD Fu Associates, Ltd. Fu Associates, Ltd. i July 2010

2 NCD Manual Changes Date Reason Release Change Edit The following section represents NCD Manual updates for July /01/10 Per CR 6964 delete ICD-9-CM codes V17.4 and V18.1 from the list of ICD-9-CM codes that are non-covered by Medicare for all Lab NCD Edits V17.4 Family history of other cardiovascular diseases V18.1 Family history of other endocrine and metabolic diseases All NCD Edits Transmittal # /01/10 Per CR 6964 add ICD-9-CM codes V17.41, V17.49, V18.11 and V18.19 to the list of ICD- 9-CM codes that are non-covered by Medicare for all Lab NCD Edits. Transmittal # V17.41 Family history of sudden cardiac death (SCD) V17.49 Family history of other cardiovascular diseases V18.11 Family history of multiple endocrine neoplasia (MEN) syndrome All NCD Edits 07/01/10 To correct a missing entry in prior versions of this Manual, the ICD-9-CM code V61.11 and its descriptor have been added as a single row in the table ICD-9-CM codes that Do Not Support Medical Necessity in Section Blood Counts. V18.19 Family history of other endocrine and metabolic diseases V61.11 Counseling for victim of spousal and partner abuse Blood Counts The following section represents NCD Manual updates for April /01/10 There were no CR updates for April The following section represents NCD Manual updates for January Fu Associates, Ltd. ii July 2010

3 Date Reason Release Change Edit 01/01/10 Per CR 6717 delete ICD-9-CM codes from the list of ICD-9-CM codes that are covered by Medicare for the Serum Iron Studies (190.18) NCD. Transmittal # Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity Chronic venous embolism and thrombosis of deep vessels of distal lower extremity Serum Iron Studies 01/01/10 Per CR 6717 add ICD-9-CM codes to the list of ICD-9-CM codes that are covered by Medicare for the Gamma Glutamyl Transferase (190.32) NCD. Transmittal # Chronic venous embolism and thrombosis of unspecified deep vessels of lower extremity Chronic venous embolism and thrombosis of deep vessels of proximal lower extremity Chronic venous embolism and thrombosis of deep vessels of distal lower extremity Gamma Glutamyl Transferase Fu Associates, Ltd. iii July 2010

4 Date Reason Release Change Edit The following section represents NCD Manual updates for October /01/09 Per CR 6548 add V20.31-V20.32 to the list of ICD-9-CM codes that are noncovered by Medicare for all Lab NCD Edits V20.31-V20.32 Health supervision for newborn under 8 days old and for newborn 8 to 28 days old All NCD Edits Transmittal # /01/09 Per CR 6548 add V60.81 and V60.89 to the list of ICD-9- CM codes that are non-covered by Medicare for all Lab NCD Edits V60.81 Foster care (status) V60.89 Other specified housing or economic circumstances All NCD Edits Transmittal # /01/09 Per CR 6548 add V80.01 and V80.09 to the list of ICD-9- CM codes that are non-covered by Medicare for all Lab NCD Edits V80.01 Special screening for traumatic brain injury V80.09 Special screening for other neurological conditions All NCD Edits Transmittal # /01/09 Per CR 6548 delete V60.8 from the list of ICD-9-CM codes non-covered by Medicare for all Lab NCD Edits V60.8 Other specified housing or economic circumstances All NCD Edits Transmittal # /01/09 Per CR 6548 delete V80.0 from the list of ICD-9-CM codes non-covered by Medicare for all Lab NCD Edits V80.0 Special screening for neurological conditions All NCD Edits Transmittal # 1766 Fu Associates, Ltd. iv July 2010

5 Date Reason Release Change Edit 10/01/09 Per CR 6548 add ICD-9-CM codes , , , , , , , , , , , , and to the list of ICD-9-CM codes that are covered by Medicare for the Urine Culture, Bacterial NCD. Transmittal # Puerperal endometritis, unspecified as to episode of care or not applicable Puerperal endometritis, delivered, with mention of postpartum complication Puerperal endometritis, postpartum condition or complication Puerperal sepsis, unspecified as to episode of care or not applicable Puerperal sepsis, delivered, with mention of postpartum complication Puerperal sepsis, postpartum condition or complication Puerperal septic thrombophlebitis, unspecified as to episode of care or not applicable Puerperal septic thrombophlebitis, delivered, with mention of postpartum complication Urine Culture, Bacterial Puerperal septic thrombophlebitis, postpartum condition or complication Other major puerperal infection, unspecified as to episode of care or not applicable Other major puerperal infection, delivered, with mention of postpartum complication Other major puerperal infection, postpartum condition or complication Colic Fu Associates, Ltd. v July 2010

6 Date Reason Release Change Edit 10/01/09 Per CR 6548 add ICD-9-CM codes V26.42, V26.82, V53.50-V53.51, V53.59, V61.07-V61.08, V61.23-V62.25, V61.42, V72.60-V72.63 and V72.69 to the list of ICD-9-CM codes that Do Not Support Medical Necessity for the Blood Counts NCD. Transmittal # V26.42 Encounter for fertility preservation counseling V26.82 Encounter for fertility preservation procedure V53.50-V53.51 Fitting and adjustment of intestinal appliance and device and of gastric lap band V53.59 Fitting and adjustment of other gastrointestinal appliance and device V61.07-V61.08 Family disruption due to death of family member and due to other extended absence of family member Blood Counts V61.23-V61.25 Counseling for parentbiological, parent-adopted and parent (guardian)- foster child problem V61.42 Substance abuse in family V72.60-V72.63 Laboratory examination, unspecified; antibody response examination; laboratory examination ordered as part of a routine general medical examination; preprocedural laboratory examination V72.69 Other laboratory examination Fu Associates, Ltd. vi July 2010

7 Date Reason Release Change Edit 10/01/09 Per CR 6548 delete ICD-9-CM codes V53.5 and V72.6 from the list of ICD- 9-CM codes that Do Not Support Medical Necessity for the Blood Counts NCD. Transmittal # /01/09 Per CR 6548 add the ICD-9-CM codes , 453.6, , , , , and to the list of ICD-9- CM codes that are covered by Medicare for the Partial Thromboplastin Time (PTT) NCD. Transmittal # V53.5 Fitting and adjustment of other intestinal appliance V72.6 Laboratory examination Chronic venous embolism and thrombosis: of unspecified deep vessels of lower extremity; of deep vessels of proximal lower extremity; and of deep vessels of distal lower extremity Venous embolism and thrombosis of superficial vessels of lower extremity Chronic venous embolism and thrombosis: of superficial veins of upper extremity; of deep veins of upper extremity; of upper extremity, unspecified; of axillary veins; of subclavian veins; of internal jugular veins; and of other thoracic veins Chronic venous embolism and thrombosis of other specified veins Acute venous embolism and thrombosis: of superficial veins of upper extremity; of deep veins of upper extremity; of upper extremity, unspecified; of axillary veins; of subclavian veins; of internal jugular veins; and of other thoracic veins Acute venous embolism and thrombosis of other specified veins Colic Blood Counts Partial Thromboplastin Time (PTT) Fu Associates, Ltd Failed moderate vii July 2010

8 Date Reason Release Change Edit 10/01/09 Per CR 6548 delete ICD-9-CM code from the list of ICD-9-CM codes that are covered by Medicare for the Partial Thromboplastin Time (PTT) NCD. Transmittal # /01/09 Per CR 6548 add ICD-9-CM codes , , , 453.6, , , , , and to the list of ICD-9- CM codes that are covered by Medicare for the Prothrombin Time (PT) NCD. Transmittal # 1766 sedation during procedure Other venous embolism and thrombosis of other specified veins Secondary neuroendocrine tumor: unspecified site; of distant lymph nodes; of liver; of bone; and of peritoneum Secondary Merkel cell carcinoma Secondary neuroendocrine tumor of other sites Chronic venous embolism and thrombosis: of unspecified deep vessels of lower extremity; of deep vessels of proximal lower extremity; and of deep vessels of distal lower extremity Venous embolism and thrombosis of superficial vessels of lower extremity Chronic venous embolism and thrombosis: of superficial veins of upper extremity; of deep veins of upper extremity; of upper extremity, unspecified; of axillary veins; of subclavian veins; of internal jugular veins; and of other thoracic veins Chronic venous embolism and thrombosis of other specified veins Partial Thromboplastin Time (PTT) Prothrombin Time (PT) Fu Associates, Ltd. viii July 2010

9 Date Reason Release Change Edit 10/01/09 (Continued) Transmittal # Acute venous embolism and thrombosis: of superficial veins of upper extremity; of deep veins of upper extremity; of upper extremity, unspecified; of axillary veins; of subclavian veins; of internal jugular veins; and of other thoracic veins Acute venous embolism and thrombosis of other specified veins Prothrombin Time (PT) (Continued) Colic 10/01/09 Per CR 6548 delete ICD-9-CM code from the list of ICD-9-CM codes that are covered by Medicare for the Prothrombin Time (PT) NCD Failed moderate sedation during procedure Other venous embolism and thrombosis of other specified veins Prothrombin Time (PT) Transmittal # /01/09 Per CR 6548 replace the duplicate ICD-9-CM code with within the list of ICD-9-CM codes that are covered by Medicare for the Prothrombin Time (PT) NCD Injury to other and multiple intra-abdominal organs without mention of open wound into cavity Prothrombin Time (PT) Transmittal # 1766 Fu Associates, Ltd. ix July 2010

10 Date Reason Release Change Edit 10/01/09 Per CR 6548 add ICD-9-CM codes , , , , , 285.3, and to the list of ICD-9-CM codes that are covered by Medicare for the Serum Iron Studies NCD. Transmittal # Merkel cell carcinoma: of the face; of the scalp and neck; of the upper limb; of the lower limb; of the trunk; and of other sites Secondary neuroendocrine tumor: unspecified site; of distant lymph nodes; of liver; of bone; and of peritoneum Secondary Merkel cell carcinoma Secondary neuroendocrine tumor of other sites Neoplasms of unspecified nature, retina and choroid Serum Iron Studies Neoplasms of unspecified nature, other specified sites Antineoplastic chemotherapy induced anemia Chronic venous embolism and thrombosis: of unspecified deep vessels of lower extremity; of deep vessels of proximal lower extremity; and of deep vessels of distal lower extremity 10/01/09 Per CR 6548 delete ICD-9-CM code from the list of ICD-9-CM codes that are covered by Medicare for the Serum Iron Studies NCD Vomiting of fecal matter Neoplasms of unspecified nature, other specified sites Serum Iron Studies Transmittal # 1766 Fu Associates, Ltd. x July 2010

11 Date Reason Release Change Edit 10/01/09 Per CR 6548 add ICD-9-CM codes , , , , , , and V10.91 to the list of ICD-9- CM codes that are covered by Medicare for the Thyroid Testing NCD. Transmittal # Autoimmune lymphoproliferative syndrome Autoimmune disease, not elsewhere classified Dysphonia, hypernasality, and hyponasality Dysarthria Other speech disturbance Nervousness; irritability; impulsiveness; emotional lability; demoralization and apathy Thyroid Testing Other signs and symptoms involving emotional state 10/01/09 Per CR 6548 delete ICD-9-CM codes 279.4, 784.5, and from the list of ICD-9-CM codes that are covered by Medicare for the Thyroid Testing NCD. V10.91 Personal history of malignant neuroendocrine tumor Autoimmune disease, not elsewhere classified Other speech disturbance Nervousness Thyroid Testing Transmittal # 1766 Fu Associates, Ltd. xi July 2010

12 Date Reason Release Change Edit 10/01/09 Per CR 6548 add ICD-9-CM codes to the list of ICD-9-CM codes that are covered by Medicare for the Lipids Testing NCD Late effects of cerebrovascular disease, dysarthria, and fluency disorder Lipids Testing Transmittal # /01/09 Per CR 6548 add ICD-9-CM codes , , and to the list of ICD-9-CM codes that are covered by Medicare for the Digoxin Therapeutic Drug Assay NCD. Transmittal # /01/09 Per CR 6548 delete ICD-9-CM code from list of ICD-9-CM codes that are covered by Medicare for the Digoxin Therapeutic Drug Assay NDC Bilious emesis Nervousness; irritability; impulsiveness; emotional lability; demoralization and apathy Other signs and symptoms involving emotional state Failed moderate sedation during procedure Digoxin Therapeutic Drug Assay Nervousness Digoxin Therapeutic Drug Assay Transmittal # /01/09 Per CR 6548 add ICD-9-CM codes and to the list of ICD-9-CM codes that are covered by Medicare for the Alpha-fetoprotein NCD. Transmittal # Secondary neuroendocrine tumor: unspecified site; of distant lymph nodes; of liver; of bone; and of peritoneum Secondary Merkel cell carcinoma Secondary neuroendocrine tumor of other sites Alpha-fetoprotein Fu Associates, Ltd. xii July 2010

13 Date Reason Release Change Edit 10/01/09 Per CR 6548 add ICD-9-CM codes and to the list of ICD-9-CM codes that are covered by Medicare for the Carcinoembryonic Antigen NCD. Transmittal # /01/09 Per CR 6548 add ICD-9-CM codes , , 453.6, , , , , , , , and to the list of ICD-9-CM codes that are covered by Medicare for the Gamma Glutamyl Transferase NCD. Transmittal # Secondary neuroendocrine tumor: unspecified site; of distant lymph nodes; of liver; of bone; and of peritoneum Secondary Merkel cell carcinoma Secondary neuroendocrine tumor of other sites Secondary neuroendocrine tumor: unspecified site; of distant lymph nodes; of liver; of bone; and of peritoneum Secondary Merkel cell carcinoma Secondary neuroendocrine tumor of other sites Venous embolism and thrombosis of superficial vessels of lower extremity Chronic venous embolism and thrombosis: of superficial veins of upper extremity; of deep veins of upper extremity; of upper extremity, unspecified; of axillary veins; of subclavian veins; of internal jugular veins; of other thoracic veins Carcinoembryonic Antigen Gamma Glutamyl Transferase 10/01/09 (Continued) Transmittal # Chronic venous embolism and thrombosis of other specified veins Gamma Glutamyl Transferase (Continued) Fu Associates, Ltd Acute venous embolism and thrombosis: of superficial veins of upper extremity; of deep veins of upper extremity; of upper extremity, unspecified; of axillary veins; of subclavian veins; of internal jugular xiii July 2010

14 Date Reason Release Change Edit veins; and of other thoracic veins Acute venous embolism and thrombosis of other specified veins Vomiting of fecal matter Poisoning by antidepressant, unspecified; by monoamine oxidase inhibitors; by selective serotonin and norepinephrine reuptake inhibitors; by selective serotonin reuptake inhibitors; by tetracyclic antidepressants; by tricyclic antidepressants Poisoning by other antidepressants Poisoning by psychostimulant, unspecified; by caffeine; by amphetamines; by methylphenidate 10/01/09 Per CR 6548 delete ICD-9-CM codes 453.8, 969.0, and from the list of ICD-9-CM codes that are covered by Medicare for the Gamma Glutamyl Transferase NCD. Transmittal # Poisoning by other psychostimulants Other venous embolism and thrombosis of other specified veins Poisoning by antidepressants Poisoning by psychostimulants Gamma Glutamyl Transferase Fu Associates, Ltd. xiv July 2010

15 Date Reason Release Change Edit 10/01/09 Per CR 6548 add ICD-9-CM codes and to the list of ICD-9- CM codes that are covered by Medicare for the Hepatitis Panel/Acute Hepatitis Panel NCD Bilious emesis Colic Hepatitis Panel/Acute Hepatitis Panel Transmittal # /01/09 Per CR 6548 add ICD-9-CM codes , , 285.3, , , and to the list of ICD-9- CM codes that are covered by Medicare for the Fecal Occult Blood Test NCD. Transmittal # Secondary neuroendocrine tumor: unspecified site; of distant lymph nodes; of liver; of bone; and of peritoneum Secondary Merkel cell carcinoma Secondary neuroendocrine tumor of other sites Antineoplastic chemotherapy induced anemia Fecal Occult Blood Test Vomiting of fecal matter Bilious emesis Colic 10/01/09 Per CR 6548 delete CPT code G0394 from the list of CPT codes covered by Medicare for the Fecal Occult Blood Test NCD. Transmittal # Failed moderate sedation during procedure G0394 Blood Occult test (e.g., guaiac), feces, for single determination for colorectal neoplasm (e.g., patient was provided three cards or single triple card for consecutive collection) Fecal Occult Blood Test The following section represents NCD Manual updates for July Fu Associates, Ltd. xv July 2010

16 Date Reason Release Change Edit 07/01/09 Per CR 6481 add ICD-9-CM codes , , , , and to the list of ICD-9-CM codes that are covered by Medicare for the Prothrombin Time NCD. Transmittal # Marginal zone lymphoma Mantle cell lymphoma Primary central nervous system lymphoma Anaplastic large cell lymphoma Large cell lymphoma Peripheral T-cell lymphoma Prothrombin Time 07/01/09 Per CR 6481 add ICD-9-CM code to the list of ICD-9-CM codes that are covered by Medicare for the Prothrombin Time NCD Chronic total occlusion of artery of the extremities Prothrombin Time Transmittal # /01/09 Per CR 6481 add ICD-9-CM codes , , , , and to the list of ICD-9-CM codes that are covered by Medicare for the Serum Iron Studies NCD Marginal zone lymphoma Mantle cell lymphoma Primary central nervous system lymphoma Anaplastic large cell lymphoma Large cell lymphoma Serum Iron Studies Transmittal # Peripheral T-cell lymphoma Fu Associates, Ltd. xvi July 2010

17 Date Reason Release Change Edit 07/01/09 Per CR 6481 add ICD-9-CM code to the list of ICD-9-CM codes that are covered by Medicare for the Lipids Testing NCD Chronic total occlusion of artery of the extremities Lipids Testing Transmittal # /01/09 Per CR 6481 add ICD-9-CM codes , , , and to the list of ICD-9-CM codes that are covered by Medicare for the Gamma Glutamyl Transferase NCD Marginal zone lymphoma Mantle cell lymphoma Primary central nervous system lymphoma Anaplastic large cell lymphoma Large cell lymphoma Gamma Glutamyl Transferase Transmittal # Peripheral T-cell lymphoma The following section represents NCD Manual updates for April /01/09 Per CR 6383 add ICD-9-CM codes , and to the list of ICD-9-CM codes that do not support Medical necessity for the Blood Counts NCD. Transmittal # /01/09 Per CR 6383 add ICD-9-CM codes and to the list of ICD-9- CM codes covered by Medicare for the Partial Thromboplastin Time NCD Osseointegration failure of dental implant Postosseointegration biological failure of dental implant Postosseointegration mechanic failure of dental implant Eosinophilic gastritis, without mention of obstruction Eosinophilic gastritis, with obstruction Blood Counts Partial Thromboplastin Time (PTT) Transmittal # 1684 Fu Associates, Ltd. xvii July 2010

18 Date Reason Release Change Edit 04/01/09 Per CR 6383 add ICD-9-CM codes 414.3, and to the list of ICD-9-CM codes covered by Medicare for the Prothrombin Time NCD. 04/01/09 04/01/09 Transmittal # 1684 Per CR 6383 add ICD-9-CM codes , , , , , , , , , , , , , , , , , , , , , , , , , , , and to the list of ICD-9- CM codes covered by Medicare for the Serum Iron Studies NCD. Transmittal # Coronary atherosclerosis due to lipid rich plaque Eosinophilic gastritis, without mention of obstruction Eosinophilic gastritis, with obstruction Multiple myeloma, in relapse Plasma cell leukemia, in relapse Other immunoproliferative neoplasms, in relapse Acute lymphoid leukemia, in relapse Chronic lymphoid leukemia, in relapse Subacute lymphoid leukemia, in relapse Other lymphoid leukemia, in relapse Unspecified lymphoid leukemia, in relapse Acute myeloid leukemia, In relapse Chronic myeloid leukemia, in relapse Subacute myeloid leukemia, in relapse Myeloid sarcoma, in relapse Other myeloid leukemia, in relapse Unspecified myeloid leukemia, in relapse Prothrombin Time Serum Iron Studies Serum Iron Studies Fu Associates, Ltd Acute monocytic leukemia, in relapse Chronic monocytic leukemia, in relapse Subacute monocytic leukemia, in xviii July 2010

19 Date Reason Release Change Edit relapse Other monocytic leukemia, in relapse Unspecified monocytic leukemia, in relapse Acute erythremia and erythroleukemia, in relapse Chronic erythremia, in relapse Megakaryocytic leukemia, in relapse Other specified leukemia, in relapse Acute leukemia of unspecified cell type, in relapse Chronic leukemia of unspecified cell type, in relapse 04/01/09 (Continued) Transmittal # Subacute leukemia of unspecified cell type, In relapse Other leukemia of unspecified cell type, in relapse Unspecified leukemia of unspecified cell type, in relapse Serum Iron Studies 04/01/09 Per CR 6383 add ICD-9-CM codes and to the list of ICD-9- CM codes covered by Medicare for the Serum Iron Studies NCD Eosinophilic gastritis, without mention of obstruction Eosinophilic gastritis, with obstruction Serum Iron Studies Transmittal # 1684 Fu Associates, Ltd. xix July 2010

20 Date Reason Release Change Edit 04/01/09 Per CR 6383 add ICD-9-CM code to the list of ICD-9-CM codes covered by Medicare for the Blood Glucose Testing NCD Coronary atherosclerosis due to lipid rich plaque Blood Glucose Testing Transmittal # /01/09 Per CR 6383 add ICD-9-CM code to the list of ICD-9-CM codes covered by Medicare for the Lipids Testing NCD. Transmittal # /01/09 04/01/09 Per CR 6383 add ICD-9-CM codes , , , , , , , , , , , , , , , , , , , , , , , , , , , to the list of ICD-9-CM codes covered by Medicare for the Gamma Glutamyl Transferase NCD. Transmittal # 1684 Fu Associates, Ltd Coronary atherosclerosis due to lipid rich plaque Multiple myeloma, in relapse Plasma cell leukemia, in relapse Other immunoproliferative neoplasms, in relapse Acute lymphoid leukemia, in relapse Chronic lymphoid leukemia, in relapse Subacute lymphoid leukemia, in relapse Other lymphoid leukemia, in relapse Unspecified lymphoid leukemia, in relapse Acute myeloid leukemia, In relapse Chronic myeloid leukemia, in relapse Subacute myeloid leukemia, in relapse Myeloid sarcoma, in relapse Other myeloid leukemia, in relapse Unspecified myeloid leukemia, in relapse Acute monocytic leukemia, in relapse xx Lipids Testing Gamma Glutamyl Transferase Gamma Glutamyl Transferase (Continued) July 2010

21 Date Reason Release Change Edit Chronic monocytic leukemia, in relapse Subacute monocytic leukemia, in relapse Other monocytic leukemia, in relapse Unspecified monocytic leukemia, in relapse Acute erythremia and erythroleukemia, in relapse Chronic erythremia, in relapse Megakaryocytic leukemia, in relapse Other specified leukemia, in relapse Acute leukemia of unspecified cell type, in relapse Chronic leukemia of unspecified cell type, in relapse Subacute leukemia of unspecified cell type, In relapse (Continued) Transmittal # /01/09 Per CR 6383 add ICD-9-CM codes , , , , , , , , , , , , , , , , , , , , , , , , and to the list of ICD-9-CM codes covered by Medicare for the Fu Associates, Ltd Other leukemia of unspecified cell type, in relapse Unspecified leukemia of unspecified cell type, in relapse Acute lymphoid leukemia, in relapse Chronic lymphoid leukemia, in relapse Subacute lymphoid leukemia, in relapse Other lymphoid leukemia, in relapse Unspecified lymphoid leukemia, in relapse Acute myeloid leukemia, In relapse Chronic myeloid leukemia, in relapse Subacute myeloid xxi Gamma Glutamyl Transferase (Continued) Fecal Occult Blood Test July 2010

22 Date Reason Release Change Edit Fecal Occult Blood Test NCD. Transmittal # /01/09 (Continued) Transmittal # 1684 leukemia, in relapse Myeloid sarcoma, in relapse Other myeloid leukemia, in relapse Unspecified myeloid leukemia, in relapse Acute monocytic leukemia, in relapse Chronic monocytic leukemia, in relapse Subacute monocytic leukemia, in relapse Other monocytic leukemia, in relapse Unspecified monocytic leukemia, in relapse Acute erythremia and erythroleukemia, in relapse Chronic erythremia, in relapse Megakaryocytic leukemia, in relapse Other specified leukemia, in relapse Acute leukemia of unspecified cell type, in relapse Chronic leukemia of unspecified cell type, in relapse Subacute leukemia of unspecified cell type, In relapse Other leukemia of unspecified cell type, in relapse Unspecified leukemia of unspecified cell type, in relapse Fecal Occult Blood Test Fu Associates, Ltd. xxii July 2010

23 Date Reason Release Change Edit 04/01/09 Per CR 6383 add ICD-9-CM codes and to the list of ICD-9- CM codes covered by Medicare for the Fecal Occult Blood Test NCD Eosinophilic gastritis, without mention of obstruction Eosinophilic gastritis, with obstruction Fecal Occult Blood Test Transmittal # 1684 The following section represents NCD Manual updates for January /01/09 Per CR 6304 add ICD-9-CM codes V16.52 and V73.81 to the list of ICD-9- CM codes denied by Medicare for all NCDs. Transmittal # /01/09 Per CR6304 add ICD-9-CM codes to the list of ICD-9-CM codes covered by Medicare for the Immunodeficiency Virus (HIV) Testing (Diagnosis) NCD V16.52 Family history of malignant neoplasm, bladder V73.81 Special screening examination for Human papillomavirus (HPV) Methicillin resistant pneumonia due to Staphylococcus aureus Non-covered ICD-9-CM Codes for All NCD Edits Human Immunodeficiency Virus (HIV) Testing (Diagnosis) Transmittal # /01/09 Per CR6304 add ICD-9-CM codes and to the list of ICD-9- CM codes covered by Medicare for the Partial Thromboplastin Time (PTT) NCD. Transmittal # Secondary diabetes mellitus with renal manifestations, not stated as uncontrolled Secondary diabetes mellitus with renal manifestations, uncontrolled Partial Thromboplastin Time (PTT) Fu Associates, Ltd. xxiii July 2010

24 Date Reason Release Change Edit 01/01/09 Per CR6304 add ICD-9-CM code to the list of ICD-9-CM codes covered by Medicare for the Prothrombin Time (PT) NCD Secondary malignant neoplasm, liver Prothrombin Time (PT) Transmittal # /01/09 Per CR6304 add ICD-9-CM codes and to the list of ICD-9- CM codes covered by the Prothrombin Time (PT) NCD. Transmittal # /01/09 Per CR6304 delete ICD-9-CM code V15.2 from the list of ICD-9-CM codes covered by Medicare for the Prothrombin Time (PT) NCD Secondary diabetes mellitus with renal manifestations, not stated as uncontrolled Secondary diabetes mellitus with renal manifestations, uncontrolled V15.2 Surgery to other organs Prothrombin Time (PT) Prothrombin Time (PT) Transmittal # /01/09 Per CR6304 add ICD-9-CM codes and V15.21, V15.22 and V15.29 to the list of ICD-9- CM codes covered by Medicare for the Prothrombin Time (PT) NCD. Transmittal # V15.21 Personal history of undergoing in utero procedure during pregnancy V15.22 Personal history of undergoing in utero procedure while a fetus V15.29 Surgery to other organs Prothrombin Time (PT) Fu Associates, Ltd. xxiv July 2010

25 Date Reason Release Change Edit 01/01/09 Per CR6304 add ICD-9-CM code ranges , , , , , , , , , , and to the list of ICD-9-CM codes covered by Medicare for the Serum Iron Studies NCD Secondary diabetes mellitus without mention of complication Secondary diabetes mellitus with ketoacidosis Secondary diabetes mellitus with hyperosmolarity Secondary diabetes mellitus with other coma Secondary diabetes mellitus with renal manifestations Serum Iron Studies Transmittal # Secondary diabetes mellitus with ophthalmic manifestations Secondary diabetes mellitus with neurological manifestations Secondary diabetes mellitus with peripheral circulatory disorders Secondary diabetes mellitus with other specified manifestations Secondary diabetes mellitus with unspecified complication Anemia in neoplastic disease Anemia of other chronic disease Fu Associates, Ltd. xxv July 2010

26 Date Reason Release Change Edit 01/01/09 Per CR6304 add ICD-9-CM codes and V15.21, V15.22 and V15.29 to the list of ICD-9- CM codes covered by Medicare for the Serum Iron Studies NCD. Transmittal # /01/09 Per CR6304 add ICD-9-CM code ranges , , , , , , , , and to the list of ICD-9-CM codes covered by Medicare for the Blood Glucose Testing NCD. Transmittal # V15.21 Personal history of undergoing in utero procedure during pregnancy V15.22 Personal history of undergoing in utero procedure while a fetus V15.29 Surgery to other organs Secondary diabetes mellitus without mention of complication Secondary diabetes mellitus with ketoacidosis Secondary diabetes mellitus with hyperosmolarity Secondary diabetes mellitus with other coma Secondary diabetes mellitus with renal manifestations Secondary diabetes mellitus with ophthalmic manifestations Secondary diabetes mellitus with neurological manifestations Serum Iron Studies Blood Glucose Testing Secondary diabetes mellitus with peripheral circulatory disorders Secondary diabetes mellitus with other specified manifestations Secondary diabetes mellitus with unspecified complication Fu Associates, Ltd. xxvi July 2010

27 Date Reason Release Change Edit 01/01/09 Per CR6304 add ICD-9-CM code to the list of ICD-9-CM codes covered by Medicare for the Blood Glucose Testing NCD Methicillin resistant pneumonia due to Staphylococcus aureus Blood Glucose Testing Transmittal # /01/09 Per CR6304 add ICD-9-CM code ranges , , , , , , , , and to the list of ICD-9-CM codes covered by Medicare for the Glycated Hemoglobin/ Glycated Protein NCD. Transmittal # Secondary diabetes mellitus without mention of complication Secondary diabetes mellitus with ketoacidosis Secondary diabetes mellitus with hyperosmolarity Secondary diabetes mellitus with other coma Secondary diabetes mellitus with renal manifestations Secondary diabetes mellitus with ophthalmic manifestations Secondary diabetes mellitus with neurological manifestations Secondary diabetes mellitus with peripheral circulatory disorders Secondary diabetes mellitus with other specified manifestations Secondary diabetes mellitus with unspecified complication Glycated Hemoglobin/Glycated Protein Fu Associates, Ltd. xxvii July 2010

28 Date Reason Release Change Edit 01/01/09 Per CR6304 add ICD-9-CM code ranges , , , , , , , , and to the list of ICD-9-CM codes covered by Medicare for the Thyroid Testing NCD Secondary diabetes mellitus without mention of complication Secondary diabetes mellitus with ketoacidosis Secondary diabetes mellitus with hyperosmolarity Secondary diabetes mellitus with other coma Secondary diabetes mellitus with renal manifestations Thyroid Testing Transmittal # Secondary diabetes mellitus with ophthalmic manifestations Secondary diabetes mellitus with neurological manifestations Secondary diabetes mellitus with peripheral circulatory disorders Secondary diabetes mellitus with other specified manifestations Secondary diabetes mellitus with unspecified complication Fu Associates, Ltd. xxviii July 2010

29 Date Reason Release Change Edit 01/01/09 Per CR6304 add ICD-9-CM code ranges , , , , , , , , and to the list of ICD-9-CM codes covered by Medicare for the Lipids Testing NCD. Transmittal # Secondary diabetes mellitus without mention of complication Secondary diabetes mellitus with ketoacidosis Secondary diabetes mellitus with hyperosmolarity Secondary diabetes mellitus with other coma Secondary diabetes mellitus with renal manifestations Secondary diabetes mellitus with ophthalmic manifestations Secondary diabetes mellitus with neurological manifestations Secondary diabetes mellitus with peripheral circulatory disorders Secondary diabetes mellitus with other specified manifestations Lipids Testing 01/01/09 Per CR6304 add ICD-9-CM code to the list of ICD-9-CM codes covered by Medicare for the Gamma Glutamyl Transferase NCD Secondary diabetes mellitus with unspecified complication Disorders of magnesium metabolism Gamma Glutamyl Transferase Transmittal #1645 Fu Associates, Ltd. xxix July 2010

30 Date Reason Release Change Edit 01/01/09 Per CR6304 add ICD-9-CM codes and to the list of ICD-9- CM codes covered by Medicare for the Fecal Occult Blood Test (FOBT) NCD Infection of esophagostomy Mechanical complication of esophagostomy Fecal Occult Blood Test (FOBT) Transmittal #1645 Fu Associates, Ltd. xxx July 2010

31 Table of Contents NCD Manual Changes... ii Table of Contents... xxxi Introduction... 1 Non-covered ICD-9-CM Codes for All NCD Edits... 4 Reasons for Denial for All NCD Edits... 6 Coding Guidelines for All NCD Edits... 7 Additional Coding Guidelines Urine Culture, Bacterial Human Immunodeficiency Virus (HIV)Testing (Prognosis Including Monitoring) Human Immunodeficiency Virus (HIV) Testing (Diagnosis) Blood Counts Partial Thromboplastin Time (PTT) Prothrombin Time (PT) Serum Iron Studies Collagen Crosslinks, Any Method Blood Glucose Testing Glycated Hemoglobin/Glycated Protein Thyroid Testing Lipids Testing Digoxin Therapeutic Drug Assay Alpha-fetoprotein Carcinoembryonic Antigen Human Chorionic Gonadotropin Tumor Antigen by Immunoassay CA Tumor Antigen by Immunoassay CA 15-3/CA Tumor Antigen by Immunoassay CA Prostate Specific Antigen Gamma Glutamyl Transferase Hepatitis Panel/Acute Hepatitis Panel Fecal Occult Blood Test Fu Associates, Ltd. xxxi July 2010

32 Background Introduction Section 4554(b)(1) of the Balanced Budget Act of 1997 (BBA), Public Law , mandated the use of a negotiated rulemaking committee to develop national coverage and administrative policies for clinical diagnostic laboratory services payable under Medicare Part B by January 1, This provision requires that these national coverage policies be designed to promote program integrity and national uniformity and simplify administrative requirements with respect to clinical diagnostic laboratory services in connection with the following: Beneficiary information required to be submitted with each claim or order for laboratory services; The medical condition for which a laboratory test is reasonable and necessary (within the meaning of section 1862(a)(1)(A) of the Social Security Act); The appropriate use of procedure codes in billing for a laboratory test, including the unbundling of laboratory services; The medical documentation that is required by a Medicare contractor at the time a claim is submitted for a laboratory test (in accordance with section 1833(e) of the Act); Record keeping requirements in addition to any information required to be submitted with a claim, including physicians obligations regarding these requirements; Procedures for filing claims and for providing remittances by electronic media; and Limitations on frequency of coverage for the same services performed on the same individual. On March 10, 2000, a proposed rule was published in the Federal Register (65 FR 13082) that set forth uniform national coverage and administrative policies for clinical diagnostic laboratory services. These proposed policies reflected the consensus of the Negotiated Rulemaking Committee. The final rule, published in the Federal Register on November 23, 2001 (66 FR 58788), addresses the public comments received on the proposed rule. The final rule established the national coverage and administrative policies for clinical diagnostic laboratory services payable under Medicare Part B. It promotes Medicare program integrity and national uniformity, and simplifies administrative requirements for clinical diagnostic services. There are 23 national coverage determinations included in the final rule listed below: Culture, Bacterial, Urine Human Immunodeficiency Virus Testing (Prognosis including monitoring) Human Immunodeficiency Virus Testing (Diagnosis) Blood Counts Partial Thromboplastin Time Prothrombin Time Serum Iron Studies Collagen Crosslinks, Any Method Blood Glucose Testing Glycated Hemoglobin/Glycated Protein Thyroid Testing Lipids Digoxin Therapeutic Drug Assay Alpha-fetoprotein Carcinoembryonic Antigen Fu Associates, Ltd. 1 July 2010

33 Human Chorionic Gonadotropin Tumor Antigen by Immunoassay - CA125 Tumor Antigen by Immunoassay CA 15-3/CA Tumor Antigen by Immunoassay CA 19-9 Prostate Specific Antigen Gamma Glutamyl Transferase Hepatitis Panel/Acute Hepatitis Panel Fecal Occult Blood What Is a National Coverage Policy? Part B of title XVIII of the Social Security Act (the Act) provides for Supplementary Medical Insurance (SMI) for certain Medicare beneficiaries, specifying what health care items or services will be covered by the Medicare Part B program. Diagnostic laboratory tests are generally covered under Part B, unless excluded from coverage by the Act. Services that are excluded from coverage include routine physical examinations and services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury. CMS interprets these provisions to prohibit coverage of screening services, including laboratory tests furnished in the absence of signs, symptoms, or personal history of disease or injury, except as explicitly authorized by statute. A test may be considered medically appropriate, but nonetheless be excluded from Medicare coverage by statute. A national coverage policy for diagnostic laboratory test(s) is a document stating CMS s policy with respect to the circumstances under which the test(s) will be considered reasonable and necessary, and not screening, for Medicare purposes. Such a policy applies nationwide. A national coverage policy is neither a practice parameter nor a statement of the accepted standard of medical practice. Words such as may be indicated or may be considered medically necessary are used for this reason. Where a policy gives a general description and then lists examples (following words like for example or including ), the list of examples is not meant to be all-inclusive but to provide some guidance. What Is the Effect of a National Coverage Policy? A national coverage policy to which this introduction applies is a National Coverage Decision (NCD) under section 1862(a) (1) of the Social Security Act. Regulations on National Coverage Decisions are codified at 42 CFR (b) (d). A Medicare contractor may not develop a local policy that conflicts with a national coverage policy. What Is the Format for These National Coverage Policies? Below are the headings for national coverage policies, developed by the Negotiated Rulemaking Committee on Clinical Diagnostic Laboratory Tests. Other Names/Abbreviations This section identifies other names for the policy. It reflects more colloquial terminology. This section includes a description of the test(s) addressed by the policy and provides a general description of the appropriate uses of the test(s). HCPCS Codes The descriptor(s) used in this section is (are) the Current Procedural Terminology (CPT) or other CMS Common Procedure Coding System (HCPCS). The CPT is developed and copyrighted by the American Medical Association (AMA). If a descriptor does not accurately or Fu Associates, Ltd. 2 July 2010

34 fully describe the test, a more complete description may be included elsewhere in the policy, such as in the Indications section. ICD 9 CM Codes Covered by Medicare Program This section includes covered codes those where there is a presumption of medical necessity, but the claim is subject to review to determine whether the test was in fact reasonable and necessary. The diagnosis codes are from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD 9 CM). Where the policy takes an exclusionary approach, as described below, this section states: Any ICD 9 CM code not listed in either of the ICD 9 CM code sections below. Indications This section lists detailed clinical indications for Medicare coverage of the test(s). Limitations This section lists any national frequency expectations, as well as other limitations on Medicare coverage of the specific test(s) addressed in the policy for example, if it would be unnecessary to perform a particular test with a particular combination of diagnoses. ICD 9 CM Codes That Do Not Support Medical Necessity This section lists/describes generally non-covered codes for which there are only limited exceptions. However, additional documentation could support a determination of medical necessity in certain circumstances. Subject to section 1879 of the Social Security Act (the Act), 42 CFR 411, subpart K, section 7330 of the Medicare Carriers Manual section of the Medicare Fiscal Intermediary Manual and any applicable rulings, it would be appropriate for the ordering physician or the laboratory to obtain an advance beneficiary notice from the beneficiary. Where the policy takes an inclusionary approach, as described below, this section states: Any ICD 9 CM code not listed in either of the ICD 9 CM sections above. Other Comments This section may contain other relevant comments that are not addressed in the sections above. Documentation Requirements This section refers to documentation requirements for clinical diagnostic laboratory tests at 42 CFR (d) and includes any specific documentation requirements related to the test(s) addressed in the policy. Sources of Information Relevant sources of information used in developing the policy are listed in this section. Fu Associates, Ltd. 3 July 2010

35 Non-covered ICD-9-CM Codes for All NCD Edits This section lists codes that are never covered. If a code from this section is given as the reason for the test, the test may be billed to the Medicare beneficiary without billing Medicare first because the service is not covered by statute, in most instances because it is performed for screening purposes and is not within an exception. The beneficiary, however, does have a right to have the claim submitted to Medicare, upon request. The individual ICD-9-CM codes included in code ranges in the table below can be viewed on CMS website under Downloads: Lab Code List. The link is: Code Sudden death, cause unknown V15.85 Personal history of contact with and (suspected) exposure to potentially hazardous body fluids V16.1 Family history of malignant neoplasm, trachea, bronchus, and lung V16.2 Family history of malignant neoplasm, other respiratory and intrathoracic organs V16.40 Family history of malignant neoplasm, genital organs V16.50 Family history of malignant neoplasm, urinary organs V16.51 Family history of malignant neoplasm, kidney V16.52 Family history of malignant neoplasm, bladder V16.59 Family history of malignant neoplasm, other V16.6 Family history of malignant neoplasm, leukemia V16.7 Family history of malignant neoplasm, other lymphatic and hematopoietic neoplasms V16.8 Family history of malignant neoplasm, other specified malignant neoplasm V16.9 Family history of malignant neoplasm, unspecified malignant neoplasm V Family history of certain chronic disabling diseases V17.41 Family history of sudden cardiac death (SCD) V17.49 Family history of other cardiovascular diseases V V17.89 Family history of asthma; other chronic respiratory conditions arthritis; other musculoskeletal diseases V18.0 Family history of diabetes mellitus V18.11 Family history of multiple endocrine neoplasia (MEN) syndrome V18.19 Family history of other endocrine and metabolic diseases V18.2-V18.4, V18.51,V18.59, V18.61, V18.69, V18.7-V18.9 Family history of anemia; other blood disorders; mental retardation; colonic polyps; other digestive disorders; polycystic kidney; other kidney diseases; other genitourinary diseases; infectious and parasitic diseases; genetic disease carrier V V19.8 Family history of other conditions V V20.2 Health supervision of infant or child V20.31 Health supervision for newborn under 8 days old V20.32 Health supervision for newborn 8 to 28 days old Fu Associates, Ltd. 4 July 2010