CMS Limitations Guide MRA Radiology Services

Transcription

1 CMS Limitations Guide MRA Radiology Services Starting July 1, 2008, CMS has placed numerous medical necessity limits on tests and procedures. This reference guide provides you with all of the latest changes. This guide is not an all-inclusive list of National Coverage Documents (NCD) and Local Coverage Documents (LCD). Please consult the CMS website for additional information at cms.hhs.gov/mcd/search.asp?clickon=search. You can search by LCD or NCD or keyword and region. CMS will deny payment if the correct diagnosis codes are not entered on the order form, and your patient s test or procedure will not be covered. We compiled this information in one location to make it easier for you to find the proper codes for medically necessary diagnoses. It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g. to the fourth or fifth digit). The correct use of an ICD-9-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination. We will continue to update this list as new CMS limitations are announced. You can always find the most current list on mymunson.org. If you have any questions, please contact Kari Smith, Office Coordinator, at (231) , or Karen Fouch, Manager, Patient Access Services, at (231) MRA of Abdomen and Pelvis (L25367)...2 MRA of Chest (L25367)...5 MRA of Head or Neck (L25367)...6 MRA of the Lower Extremities...13 Non-covered services ICD-9-CM codes do not support the medical necessity for CPT codes listed below as they are always non-covered MAGNETIC RESONANCE ANGIOGRAPHY, SPINAL CANAL AND CONTENTS, WITH OR WITHOUT CONTRAST MATERIAL(S) MAGNETIC RESONANCE ANGIOGRAPHY, UPPER EXTREMITY, WITH OR WITHOUT CONTRAST MATERIAL(S) - 1 -

2 MRA of Abdomen and Pelvis (L25367) BENIGN NEOPLASM OF KIDNEY EXCEPT PELVIS MALIGNANT ESSENTIAL HYPERTENSION BENIGN ESSENTIAL HYPERTENSION HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT 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 I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 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, WITHOUT 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 WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT 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 CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT 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 WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE MALIGNANT RENOVASCULAR HYPERTENSION BENIGN RENOVASCULAR HYPERTENSION - 2 -

3 UNSPECIFIED RENOVASCULAR HYPERTENSION ATHEROSCLEROSIS OF AORTA ATHEROSCLEROSIS OF RENAL ARTERY ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE DISSECTION OF AORTA ABDOMINAL DISSECTION OF AORTA THORACOABDOMINAL ABDOMINAL ANEURYSM WITHOUT RUPTURE THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE ANEURYSM OF RENAL ARTERY ANEURYSM OF ILIAC ARTERY ANEURYSM OF ARTERY OF LOWER EXTREMITY ANEURYSM OF SPLENIC ARTERY ANEURYSM OF OTHER VISCERAL ARTERY ANEURYSM OF OTHER SPECIFIED SITE DISSECTION OF ILIAC ARTERY DISSECTION OF RENAL ARTERY PERIPHERAL VASCULAR DISEASE UNSPECIFIED EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA EMBOLISM AND THROMBOSIS OF THORACIC AORTA EMBOLISM AND THROMBOSIS OF ILIAC ARTERY ATHEROEMBOLISM OF KIDNEY ARTERIOVENOUS FISTULA ACQUIRED STRICTURE OF ARTERY HYPERPLASIA OF RENAL ARTERY NECROSIS OF ARTERY OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES ACUTE VASCULAR INSUFFICIENCY OF INTESTINE CHRONIC VASCULAR INSUFFICIENCY OF INTESTINE ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS ACUTE KIDNEY FAILURE WITH LESION OF RENAL CORTICAL NECROSIS - 3 -

4 584.7 ACUTE KIDNEY FAILURE WITH LESION OF RENAL MEDULLARY [PAPILLARY] NECROSIS ACUTE KIDNEY FAILURE WITH OTHER SPECIFIED PATHOLOGICAL LESION IN KIDNEY ACUTE KIDNEY FAILURE, UNSPECIFIED CHRONIC KIDNEY DISEASE, STAGE I CHRONIC KIDNEY DISEASE, STAGE II (MILD) CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE CHRONIC KIDNEY DISEASE, UNSPECIFIED 587 RENAL SCLEROSIS UNSPECIFIED UNILATERAL SMALL KIDNEY BILATERAL SMALL KIDNEYS SMALL KIDNEY UNSPECIFIED VASCULAR DISORDERS OF KIDNEY RENAL VESSEL ANOMALY LOWER LIMB VESSEL ANOMALY 793.6* NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF ABDOMINAL AREA, INCLUDING RETROPERITONEUM INJURY TO ABDOMINAL AORTA INJURY TO RENAL VESSEL(S) UNSPECIFIED INJURY TO RENAL ARTERY INJURY TO ILIAC VESSEL(S) UNSPECIFIED INJURY TO HYPOGASTRIC ARTERY INJURY TO ILIAC ARTERY MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT OTHER COMPLICATIONS DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT COMPLICATIONS OF TRANSPLANTED KIDNEY V42.0 KIDNEY REPLACED BY TRANSPLANT V58.73 AFTERCARE FOLLOWING SURGERY OF THE CIRCULATORY SYSTEM NOT ELSEWHERE CLASSIFIED V59.4 KIDNEY DONORS V70.8 OTHER SPECIFIED GENERAL MEDICAL EXAMINATIONS - 4 -

5 MRA of Chest (L25367) ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC ACUTE COR PULMONALE IATROGENIC PULMONARY EMBOLISM AND INFARCTION SEPTIC PULMONARY EMBOLISM OTHER PULMONARY EMBOLISM AND INFARCTION DISSECTION OF AORTA THORACIC DISSECTION OF AORTA THORACOABDOMINAL THORACIC ANEURYSM WITHOUT RUPTURE THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE EMBOLISM AND THROMBOSIS OF THORACIC AORTA ACUTE KIDNEY FAILURE, UNSPECIFIED CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) CHRONIC KIDNEY DISEASE, STAGE V END STAGE RENAL DISEASE 586 RENAL FAILURE UNSPECIFIED COARCTATION OF AORTA (PREDUCTAL) (POSTDUCTAL) INTERRUPTION OF AORTIC ARCH MARFAN SYNDROME 793.2* NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF OTHER INTRATHORACIC ORGANS NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF PULMONARY SYSTEM V12.59 PERSONAL HISTORY OF OTHER DISEASES OF CIRCULATORY SYSTEM NOT ELSEWHERE CLASSIFIED V14.8 PERSONAL HISTORY OF ALLERGY TO OTHER SPECIFIED MEDICINAL AGENTS V15.08 PERSONAL HISTORY OF ALLERGY TO RADIOGRAPHIC DYE V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY - 5 -

6 MRA of Head or Neck (L25367) MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID MALIGNANT NEOPLASM OF ORBIT MALIGNANT NEOPLASM OF LACRIMAL GLAND MALIGNANT NEOPLASM OF CONJUNCTIVA MALIGNANT NEOPLASM OF CORNEA MALIGNANT NEOPLASM OF RETINA MALIGNANT NEOPLASM OF CHOROID MALIGNANT NEOPLASM OF LACRIMAL DUCT MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE 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 MALIGNANT NEOPLASM OF CEREBRAL MENINGES 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 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM BENIGN NEOPLASM OF BRAIN BENIGN NEOPLASM OF CRANIAL NERVES BENIGN NEOPLASM OF CEREBRAL MENINGES BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT BENIGN NEOPLASM OF PINEAL GLAND BENIGN NEOPLASM OF CAROTID BODY BENIGN NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA - 6 -

7 HEMANGIOMA OF INTRACRANIAL STRUCTURES HEMANGIOMA OF RETINA NEOPLASM OF UNCERTAIN BEHAVIOR OF BRAIN AND SPINAL CORD NEOPLASM OF UNCERTAIN BEHAVIOR OF MENINGES NEUROFIBROMATOSIS UNSPECIFIED NEUROFIBROMATOSIS TYPE 1 VON RECKLINGHAUSEN'S DISEASE NEUROFIBROMATOSIS TYPE 2 ACOUSTIC NEUROFIBROMATOSIS NEOPLASM OF UNSPECIFIED NATURE OF BRAIN SICKLE-CELL DISEASE UNSPECIFIED 325 PHLEBITIS AND THROMBOPHLEBITIS OF INTRACRANIAL VENOUS SINUSES TRIGEMINAL NEURALGIA ATYPICAL FACE PAIN OTHER SPECIFIED TRIGEMINAL NERVE DISORDERS RETINAL VASCULAR OCCLUSION UNSPECIFIED CENTRAL RETINAL ARTERY OCCLUSION RETINAL ARTERIAL BRANCH OCCLUSION PARTIAL RETINAL ARTERIAL OCCLUSION TRANSIENT RETINAL ARTERIAL OCCLUSION TRANSIENT VISUAL LOSS VISUAL FIELD DEFECT UNSPECIFIED HOMONYMOUS BILATERAL FIELD DEFECTS HETERONYMOUS BILATERAL FIELD DEFECTS PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE FOSTER-KENNEDY SYNDROME HEMORRHAGE IN OPTIC NERVE SHEATHS DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS DISORDERS OF OPTIC CHIASM ASSOCIATED WITH OTHER NEOPLASMS DISORDERS OF OPTIC CHIASM ASSOCIATED WITH VASCULAR DISORDERS DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH VASCULAR DISORDERS DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS DISORDERS OF VISUAL CORTEX ASSOCIATED WITH VASCULAR DISORDERS THIRD OR OCULOMOTOR NERVE PALSY PARTIAL THIRD OR OCULOMOTOR NERVE PALSY TOTAL - 7 -

8 FOURTH OR TROCHLEAR NERVE PALSY SIXTH OR ABDUCENS NERVE PALSY 430 SUBARACHNOID HEMORRHAGE 431 INTRACEREBRAL HEMORRHAGE NONTRAUMATIC EXTRADURAL HEMORRHAGE SUBDURAL HEMORRHAGE UNSPECIFIED INTRACRANIAL HEMORRHAGE OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF CAROTID ARTERY WITHOUT CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITHOUT CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITHOUT CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY WITHOUT CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITHOUT CEREBRAL INFARCTION OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT CEREBRAL INFARCTION CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION BASILAR ARTERY SYNDROME VERTEBRAL ARTERY SYNDROME SUBCLAVIAN STEAL SYNDROME UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA CEREBRAL ANEURYSM NONRUPTURED ANEURYSM OF ARTERY OF NECK ANEURYSM OF SUBCLAVIAN ARTERY - 8 -

9 DISSECTION OF CAROTID ARTERY DISSECTION OF VERTEBRAL ARTERY TAKAYASU'S DISEASE ARTERIOVENOUS FISTULA ACQUIRED STRICTURE OF ARTERY RUPTURE OF ARTERY NECROSIS OF ARTERY OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM SYNCOPE AND COLLAPSE DIZZINESS AND GIDDINESS * OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEMS SWELLING MASS OR LUMP IN HEAD AND NECK NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS - 9 -

10 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED

11 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN 1 HOUR) LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED INJURY TO CAROTID ARTERY UNSPECIFIED INJURY TO COMMON CAROTID ARTERY INJURY TO EXTERNAL CAROTID ARTERY INJURY TO INTERNAL CAROTID ARTERY INJURY TO MULTIPLE BLOOD VESSELS OF HEAD AND NECK INJURY TO OTHER SPECIFIED BLOOD VESSELS OF HEAD AND NECK LATE EFFECT OF INJURY TO BLOOD VESSEL OF HEAD NECK AND EXTREMITIES

12 996.1 MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT MECHANICAL COMPLICATION OF NERVOUS SYSTEM DEVICE IMPLANT AND GRAFT * - Use for patients presenting with signs and symptoms strongly suggesting an intracerebral aneurysm, without the MRA finding of an aneurysm

13 MRA of the Lower Extremities HEMANGIOMA OF OTHER SITES DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE EXTREMITIES ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTREMITIES ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES ANEURYSM OF ILIAC ARTERY ANEURYSM OF ARTERY OF LOWER EXTREMITY THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE) DISSECTION OF ILIAC ARTERY DISSECTION OF OTHER ARTERY PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE PERIPHERAL VASCULAR DISEASE UNSPECIFIED ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY EMBOLISM AND THROMBOSIS OF ILIAC ARTERY EMBOLISM AND THROMBOSIS OF OTHER ARTERY ATHEROEMBOLISM OF LOWER EXTREMITY STRICTURE OF ARTERY NECROSIS OF ARTERY ARTERITIS UNSPECIFIED OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES LOWER LIMB VESSEL ANOMALY ANOMALIES OF OTHER SPECIFIED SITES OF PERIPHERAL VASCULAR SYSTEM GANGRENE

14 904.0 INJURY TO COMMON FEMORAL ARTERY INJURY TO SUPERFICIAL FEMORAL ARTERY INJURY TO POPLITEAL ARTERY INJURY TO ANTERIOR TIBIAL ARTERY INJURY TO POSTERIOR TIBIAL ARTERY MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY V67.59 OTHER FOLLOW-UP EXAMINATION