2013 NATIONAL COVERAGE DETERMINATION (NCD) CPT CODE(S): 82728, 83540, 83550, IRON - SERUM

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1 ABNORMALITY OF RED BLOOD CELLS ABSCESS OF LIVER 570 ACUTE AND SUBACUTE NECROSIS OF LIVER ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, IN RELAPSE ACUTE ERYTHREMIA AND ERYTHROLEUKEMIA, WITHOUT MENTION OF HAVING ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACUTE LYMPHOID LEUKEMIA, IN RELAPSE ACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING ACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING ACUTE MONOCYTIC LEUKEMIA, IN RELAPSE ACUTE MYELOID LEUKEMIA, IN RELAPSE ACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION AND IN REMISSION ACUTE POST-HEMORRHAGIC ANEMIA ACUTE VASCULAR INSUFFICIENCY OF INTESTINE ALCOHOLIC CARDIOMYOPATHY ALOPECIA AMEBIASIS ANAPLASTIC LARGE CELL LYMPHOMA ANEMIA IN CHRONIC KIDNEY DISEASE ANEMIA IN NEOPLASTIC DISEASE ANEMIA OF OTHER CHRONIC DISEASE ANEMIA, UNSPECIFIED ANGIODYSPLASIA OF INTESTINE WITH HEMORRHAGE Page 1 of 13

2 ANGIODYSPLASIA OF STOMACH AND DUODENUM WITH HEMORRHAGE ANOREXIA NERVOSA ANTINEOPLASTIC CHEMOTHERAPY INDUCED ANEMIA ARTHROPATHY ASSOCIATED WITH OTHER ENDOCRINE AND METABOLIC DISORDERS V08 ASYMPTOMATIC HIV INFECTION ATROPHY OF TESTIS BACTERIAL ENTERITIS, UNSPECIFIED , BENIGN CARCINOID TUMOR OF OTHER AND UNSPECIFIED SITES BENIGN CARCINOID TUMORS OF THE APPENDIX, LARGE INTESTINE AND RECTUM BENIGN CARCINOID TUMORS OF THE SMALL INTESTINE BENIGN NEOPLASMS V43.4 BLOOD VESSEL REPLACED BY OTHER MEANS CACHEXIA CARCINOMA IN SITU (VARIOUS) CARCINOMA IN SITU (VARIOUS) CARCINOMA IN SITU, OTHER FEMALE GENITAL ORGAN CARCINOMA IN SITU, UNSPECIFIED FEMALE GENITAL ORGAN CARCINOMA IN SITU, VAGINA CARCINOMA IN SITU, VULVA CARDIAC DYSRHYTHMIAS CARDIOMYOPATHY IN OTHER DISEASES CLASSIFIED ELSEWHERE CHRONIC ERYTHREMIA, IN RELAPSE CHRONIC ERYTHREMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION AND IN REMISSION CHRONIC KIDNEY DISEASE Page 2 of 13

3 CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING CHRONIC LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE CHRONIC LIVER DISEASE AND CIRRHOSIS CHRONIC LYMPHOID LEUKEMIA, IN RELAPSE CHRONIC LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING CHRONIC MONOCYTIC LEUKEMIA, IN RELAPSE CHRONIC MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING CHRONIC MYELOID LEUKEMIA, IN RELAPSE CHRONIC MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING CHRONIC VASCULAR INSUFFICIENCY OF INTESTINE COAGULATION DEFECTS (CONGENITAL FACTOR DISORDERS) COMPLICATIONS OF TRANSPLANTED ORGAN, BONE MARROW , , CONDUCTION DISORDERS DIABETES MELLITUS DIEULAFOY LESION (HEMORRHAGIC) OF INTESTINE DIEULAFOY LESION (HEMORRHAGIC) OF STOMACH AND DUODENUM DISORDERS OF FUNCTION OF STOMACH DISORDERS OF IRON METABOLISM DISORDERS OF MENSTRUATION AND OTHER ABNORMAL BLEEDING FROM FEMALE GENITAL TRACT DISORDERS OF PORPHYRIN METABOLISM DIVERTICULITIS OF COLON WITH HEMORRHAGE DIVERTICULITIS OF SMALL INTESTINE WITH HEMORRHAGE DIVERTICULOSIS OF COLON WITH HEMORRHAGE Page 3 of 13

4 DIVERTICULOSIS OF SMALL INTESTINE WITH HEMORRHAGE DUODENAL ULCER DYSCHROMIA ENTERITIS DUE TO ADENOVIRUS ENTERITIS DUE TO ASTROVIRUS ENTERITIS DUE TO CALICIVIRUS ENTERITIS DUE TO ENTEROVIRUS, NOT ELSEWHERE CLASSIFIED ENTERITIS DUE TO NORWALK VIRUS ENTERITIS DUE TO OTHER SMALL ROUND VIRUSES (SRVS) ENTERITIS DUE TO ROTAVIRUS EOSINOPHILIC GASTRITIS, WITH OBSTRUCTION EOSINOPHILIC GASTRITIS, WITHOUT MENTION OF OBSTRUCTION ESOPHAGEAL HEMORRHAGE V56.0 EXTRACORPOREAL DIALYSIS GASTRIC ULCER GASTRITIS AND DUODENITIS GASTROESOPHAGEAL LACERATION-HEMORRHAGE SYNDROME GASTROINTESTINAL HEMORRHAGE GASTROJEJUNAL ULCER HEART FAILURE V43.21-V43.22 HEART REPLACED BY OTHER MEANS V43.3 HEART VALVE REPLACED BY OTHER MEANS HEMOLYTIC DISEASE DUE TO OTHER AND UNSPECIFIED ISOIMMUNIZATION HEMORRHAGE OF RECTUM AND ANUS HEPATIC ENCEPHALOPATHY HEPATORENAL SYNDROME HODGKIN S DISEASE 042 HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE Page 4 of 13

5 773.3 HYDROPS FETALIS DUE TO ISOIMMUNIZATION HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE WITHOUT HEART FAILURE & WITH CHRONIC KIDNEY DISEASE STAGE OR END STAGE RENAL DISEASE HYPERTENSIVE HEART & CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE & WITH CHRONIC KIDNEY DISEASE STAGE OR END STAGE RENAL DISEASE HYPERTENSIVE HEART & CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE & WITH CHRONIC KIDNEY DISEASE STAGE V HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE & 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 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE & WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE IATROGENIC PITUITARY DISORDERS ILL-DEFINED INTESTINAL INFECTIONS INTESTINAL INFECTIONS DUE TO AEROBACTER AEROGENES INTESTINAL INFECTIONS DUE TO ARIZONA GROUP OF PARACOLON BACILLI INTESTINAL INFECTIONS DUE TO CAMPYLOBACTER Page 5 of 13

6 INTESTINAL INFECTIONS DUE TO CLOSTRIDIUM DIFFICILE INTESTINAL INFECTIONS DUE TO ENTEROHEMORRHAGIC E. COLI INTESTINAL INFECTIONS DUE TO ENTEROINVASIVE E. COLI INTESTINAL INFECTIONS DUE TO ENTEROPATHOGENIC E. COLI INTESTINAL INFECTIONS DUE TO ENTEROTOXIGENIC E. COLI INTESTINAL INFECTIONS DUE TO ESCHERICHIA COLI [E. COLI], UNSPECIFIED INTESTINAL INFECTIONS DUE TO OTHER ANAEROBES INTESTINAL INFECTIONS DUE TO OTHER BACTERIA INTESTINAL INFECTIONS DUE TO OTHER GRAM-NEGATIVE BACTERIA INTESTINAL INFECTIONS DUE TO OTHER INTESTINAL E. COLI ORGANISMS INTESTINAL INFECTIONS DUE TO OTHER ORGANISMS, NOT ELSEWHERE CLASSIFIED INTESTINAL INFECTIONS DUE TO PROTEUS (MIRABILIS) (MORGANII) INTESTINAL INFECTIONS DUE TO PSEUDOMONAS INTESTINAL INFECTIONS DUE TO STAPHYLOCOCCUS INTESTINAL INFECTIONS DUE TO YERSINIA ENTEROCOLITIS INTESTINAL MALABSORPTION IRON DEFICIENCY ANEMIAS KERNICTERUS DUE TO ISOIMMUNIZATION 260 KWASHIORKOR LARGE CELL LYMPHOMA LATE ANEMIA DUE TO ISOIMMUNIZATION LYMPHOSARCOMA AND RETICULOSARCOMA; BURKITT S TUMOR OR LYMPHOMA , MALIGNANT CARCINOID TUMORS OF OTHER AND UNSPECIFIED SITES Page 6 of 13

7 MALIGNANT CARCINOID TUMORS OF THE APPENDIX, LARGE INTESTINE AND RECTUM MALIGNANT CARCINOID TUMORS OF THE SMALL INTESTINE MALIGNANT NEOPLASM ASSOCIATED WITH TRANSPLANTED ORGAN MALIGNANT NEOPLASM OF BONE, CONNECTIVE TISSUE, SKIN AND BREAST MALIGNANT NEOPLASM OF DIGESTIVE ORGANS AND PERITONEUM MALIGNANT NEOPLASM OF GENITOURINARY ORGANS MALIGNANT NEOPLASM OF LIP ORAL CAVITY AND PHARYNX MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES MALIGNANT NEOPLASM OF RESPIRATORY AND INTRATHORACIC ORGANS MALIGNANT POORLY DIFFERENTIATED NEUROENDOCRINE TUMOR, ANY SITE MALIGNANT TUMORS OF LYMPHATIC TISSUE; OTHER NAMED VARIANTS MANTLE CELL LYMPHOMA MARGINAL ZONE LYMPHOMA MEGAKARYOCYTIC LEUKEMIA, IN RELAPSE MEGAKARYOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING MERKEL CELL CARCINOMA OF OTHER SITES MERKEL CELL CARCINOMA OF THE FACE MERKEL CELL CARCINOMA OF THE LOWER LIMB MERKEL CELL CARCINOMA OF THE SCALP AND NECK MERKEL CELL CARCINOMA OF THE TRUNK MERKEL CELL CARCINOMA OF THE UPPER LIMB MULTIPLE MYELOMA, IN RELAPSE MULTIPLE MYELOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION AND IN REMISSION Page 7 of 13

8 MYELOID SARCOMA, IN RELAPSE MYELOID SARCOMA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION AND IN REMISSION , , , , , , , NEOPLASMS OF UNCERTAIN BEHAVIOR , 238.8, NEOPLASMS OF UNCERTAIN BEHAVIOR NEOPLASMS OF UNSPECIFIED NATURE NEOPLASMS OF UNSPECIFIED NATURE, OTHER SPECIFIED SITES NEOPLASMS OF UNSPECIFIED NATURE, RETINA AND CHOROID NEOPLASMS OF UNSPECIFIED NATURE, SITE UNSPECIFIED NEPHROTIC SYNDROME NONSPECIFIC ELEVATION OF LEVELS OF TRANSAMINASE OR LACTIC ACID DEHYDROGENASE [LDH] NUTRITIONAL AND METABOLIC CARDIOMYOPATHY 261 NUTRITIONAL MARASMUS OTHER SEQUELAE OF CHRONIC LIVER DISEASE OTHER ABNORMAL BLOOD CHEMISTRY OTHER AND UNSPECIFIED ARTHROPATHIES OTHER AND UNSPECIFIED DISORDERS OF EATING OTHER AND UNSPECIFIED PROTEIN-CALORIE MALNUTRITION OTHER CURRENT CONDITIONS IN THE MOTHER CLASSIFIABLE ELSEWHERE, BUT COMPLICATING PREGNANCY, CHILDBIRTH, OR THE PUERPERIUM: ANEMIA Page 8 of 13

9 OTHER DEFICIENCY ANEMIAS V56.8 OTHER DIALYSIS OTHER DISORDERS OF LIVER OTHER DISORDERS OF THE PITUITARY AND OTHER SYNDROMES OF DIENCEPHALOHYPOPHYSIAL ORIGIN OTHER IMMUNOPROLIFERATIVE NEOPLASMS, IN RELAPSE OTHER IMMUNOPROLIFERATIVE NEOPLASMS, WITHOUT MENTION OF HAVING OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE OTHER LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING OTHER LYMPHOID LEUKEMIA, IN RELAPSE OTHER LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING OTHER LYMPHOMAS; OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE OTHER MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE OTHER MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING OTHER MONOCYTIC LEUKEMIA, IN RELAPSE OTHER MYELOID LEUKEMIA, IN RELAPSE OTHER MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION AND IN REMISSION OTHER NONSPECIFIC ABNORMAL SERUM ENZYME LEVELS OTHER OVARIAN FAILURE OTHER PRIMARY CARDIOMYOPATHIES OTHER PROTOZOAL INTESTINAL DISEASES OTHER SALMONELLA INFECTIONS Page 9 of 13

10 262 OTHER SEVERE PROTEIN-CALORIE MALNUTRITION OTHER SICKLE-CELL DISEASE WITH CRISIS OTHER SICKLE-CELL DISEASE WITHOUT CRISIS OTHER SPECIFIED AND UNSPECIFIED INTESTINAL MALABSORPTION OTHER SPECIFIED LEUKEMIA, IN RELAPSE OTHER SPECIFIED LEUKEMIA, WITHOUT MENTION OF HAVING OTHER SYMPTOMS CONCERNING NUTRITION, METABOLISM AND DEVELOPMENT OTHER TESTICULAR HYPOFUNCTION OTHER AND UNSPECIFIED INFUSION AND TRANSFUSION REACTION OTHER VIRAL ENTERITIS PAIN IN JOINT PANHYPOPITUITARISM PEPTIC ULCER, SITE UNSPECIFIED PERIPHERAL T-CELL LYMPHOMA V12.3 PERSONAL HISTORY OF DISEASES OF BLOOD AND BLOOD FORMING ORGANS V12.1 PERSONAL HISTORY OF NUTRITIONAL DEFICIENCY V15.1 PERSONAL HISTORY OF SURGERY TO HEART AND GREAT VESSELS V15.21 PERSONAL HISTORY OF UNDERGOING IN UTERO PROCEDURE DURING PREGNANCY V15.22 PERSONAL HISTORY OF UNDERGOING IN UTERO PROCEDURE WHILE A FETUS PHYSIOLOGICAL MALFUNCTION ARISING FROM MENTAL FACTORS, GASTROINTESTINAL PLASMA CELL LEUKEMIA, IN RELAPSE PLASMA CELL LEUKEMIA, WITHOUT MENTION OF HAVING ACHIEVED REMISSION AND IN REMISSION Page 10 of 13

11 964.0 POISONING BY AGENTS PRIMARILY AFFECTING BLOOD CONSTITUENTS, IRON COMPOUNDS PORTAL HYPERTENSION PORTAL PYEMIA POSTMENOPAUSAL BLEEDING POST-TRANSPLANT LYMPHOPROLIFERATIVE DISORDER (PTLD) PREMENOPAUSAL MENORRHAGIA PRIMARY CENTRAL NERVOUS SYSTEM LYMPHOMA PRURITUS AND RELATED CONDITIONS PURPURA AND OTHER HEMORRHAGIC CONDITIONS REGIONAL ENTERITIS 586 RENAL FAILURE, UNSPECIFIED SECONDARY CARDIOMYOPATHY, UNSPECIFIED SECONDARY DIABETES MELLITUS WITH HYPEROSMOLARITY SECONDARY DIABETES MELLITUS WITH KETOACIDOSIS SECONDARY DIABETES MELLITUS WITH NEUROLOGICAL MANIFESTATIONS SECONDARY DIABETES MELLITUS WITH OPHTHALMIC MANIFESTATIONS SECONDARY DIABETES MELLITUS WITH OTHER COMA MANIFESTATIONS SECONDARY DIABETES MELLITUS WITH PERIPHERAL CIRCULATORY DISORDERS SECONDARY DIABETES MELLITUS WITH RENAL MANIFESTATIONS SECONDARY DIABETES MELLITUS WITH UNSPECIFIED COMPLICATION SECONDARY DIABETES MELLITUS WITHOUT MENTION OF COMPLICATION SECONDARY MERKEL CELL CARCINOMA Page 11 of 13

12 SECONDARY NEUROENDOCRINE TUMOR OF BONE SECONDARY NEUROENDOCRINE TUMOR OF DISTANT LYMPH NODES SECONDARY NEUROENDOCRINE TUMOR OF LIVER SECONDARY NEUROENDOCRINE TUMOR OF OTHER SITES SECONDARY NEUROENDOCRINE TUMOR OF PERITONEUM SECONDARY NEUROENDOCRINE TUMOR, UNSPECIFIED SITE SICKLE-CELL DISEASES SICKLE-CELL/HGB C DISEASE WITH CRISIS SIDEROBLASTIC ANEMIA (INCLUDES HEMOCHROMATOSIS WITH REFRACTORY ANEMIA) SPLENDID SEQUESTRATION SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE SUBACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING SUBACUTE LYMPHOID LEUKEMIA, IN RELAPSE SUBACUTE LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING SUBACUTE MONOCYTIC LEUKEMIA, IN RELAPSE SUBACUTE MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING SUBACUTE MYELOID LEUKEMIA, IN RELAPSE SUBACUTE MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING V15.29 SURGERY TO OTHER ORGANS THALASSEMIAS TOXIC EFFECT OF LEAD AND ITS COMPOUNDS (INCLUDING FUMES) TUBERCULOSIS OF BLADDER TUBERCULOSIS OF BONES AND JOINTS Page 12 of 13

13 TUBERCULOSIS OF INTESTINES, PERITONEUM, AND MESENTERIC GLANDS TUBERCULOSIS OF KIDNEY TUBERCULOSIS OF OTHER URINARY ORGANS TUBERCULOSIS OF URETER TUBERCULOUS BRONCHIECTASIS TYPHOID AND PARATYPHOID FEVERS ULCERATIVE COLITIS V43.60 UNSPECIFIED JOINT REPLACED BY OTHER MEANS UNSPECIFIED LEUKEMIA OF UNSPECIFIED CELL TYPE, IN RELAPSE UNSPECIFIED LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING UNSPECIFIED LYMPHOID LEUKEMIA, IN RELAPSE UNSPECIFIED LYMPHOID LEUKEMIA, WITHOUT MENTION OF HAVING UNSPECIFIED MONOCYTIC LEUKEMIA, IN RELAPSE UNSPECIFIED MONOCYTIC LEUKEMIA, WITHOUT MENTION OF HAVING UNSPECIFIED MYELOID LEUKEMIA, IN RELAPSE UNSPECIFIED MYELOID LEUKEMIA, WITHOUT MENTION OF HAVING Page 13 of 13

NCD for Serum Iron Studies

NCD for Serum Iron Studies Applicable CPT Code(s): 82728 Ferritin 83540 Iron 83550 Iron Binding capacity 84466 Transferrin ICD-9 Codes that Support Medical Necessity: Code Description 790.01-790.09 Abnormality