Contractor Information. LCD Information. Local Coverage Determination (LCD): Ophthalmoscopy (L34017) Document Information

Transcription

1 Local Coverage Determination (LCD): Ophthalmoscopy (L34017) Links in PDF documents are not guaranteed to work. To follow a web link, please use the MCD Website. Contractor Information Contractor Name Contract Type Contract Number Jurisdiction State(s) First Coast Service Options, Inc. A and B MAC MAC A J - N Florida First Coast Service Options, Inc. A and B MAC MAC B J - N Florida First Coast Service Options, Inc. A and B MAC MAC A J - N Puerto Rico Virgin Islands First Coast Service Options, Inc. A and B MAC MAC B J - N Puerto Rico First Coast Service Options, Inc. A and B MAC MAC B J - N Virgin Islands Back to Top LCD Information Document Information LCD ID L34017 Original ICD-9 LCD ID L28940 LCD Title Ophthalmoscopy Proposed LCD in Comment Period Source Proposed LCD AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT only copyright American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 10/01/2017 Revision Ending Date Retirement Date Notice Period Start Date Notice Period End Date The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright American Dental Association. All rights reserved. CDT and CDT-2016 are trademarks of the American Dental Association. Printed on 10/3/2017. Page 1 of 10

2 UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL, 2014, is copyrighted by American Hospital Association ( AHA ), Chicago, Illinois. No portion of OFFICIAL UB-04 MANUAL may be reproduced, sorted in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior express, written consent of AHA. Health Forum reserves the right to change the copyright notice from time to time upon written notice to Company. CMS National Coverage Policy Language quoted from CMS National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals are italicized throughout the Local Coverage Determination (LCD). NCDs and coverage provisions in interpretive manuals are not subject to the LCD Review Process (42 CFR [b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See 1869 (f)(1)(a)(i) of the Social Security Act. Unless other wise specified, italicized text represents quotation from one or more of the following CMS sources: Coverage Guidance Coverage Indications, Limitations, and/or Medical Necessity Extended ophthalmoscopy is an assessment of the posterior segment of the (vitreous, retina, optic disc, choroids, etc.) with the pupil dilated using indirect ophthalmoscopy or slit lamp biomicroscopy. These techniques employ an additional diagnostic tool (eg, 3-mirror lens, 20-diopter lens, 90-diopter lens, scleral depression) and include a detailed drawing of the retina. Extended ophthalmoscopy provides a high intensity illumination, stereoscopic, wide field of view of the ocular fundus for detection and/or evaluation of vitreoretinal pathology. Extended ophthalmoscopy codes are reserved for the meticulous evaluation of the in detailed documentation of a severe ophthalmologic problem needing continued follow-up, which cannot be sufficiently evaluated by photography. Ophthalmoscopy (CPT Codes 92225, 92226) will be considered medically reasonable and necessary if any one of the following circumstances is present: The patient has a malignant neoplasm of the retina or choroid. This may appear as a single, round or oval, slightly elevated, gray or nonpigmented lesion. The patient has a retained (old) intraocular foreign body, either magnetic or nonmagnetic. Signs and symptoms may include a statement by the patient that something has hit his/her (foreign body sensation), normal or blurred vision, pain or no discomfort, and tearing. The patient has retinal hemorrhage, edema, ischemia, exudates and deposits, hereditary retinal dystrophies or peripheral retinal degeneration. The patient has retinal detachment with or without retinal defect. The patient may complain of light flashes, dark floating specks, and blurred vision that becomes progressively worse. This may be described by the patient as a curtain came down over my s. The patient has retinal defects without retinal detachment. The patient has diabetic retinopathy (e.g., background retinopathy or proliferative retinopathy), retinal vascular occlusion, or separation of the retinal layers. This may be evidenced by microaneurysms, cotton wool spots, exudates, hemorrhages, or fibrous proliferation. The patient has experienced sudden visual loss or transient visual loss. This may be described as trouble seeing or vision going in and out. The patient has chorioretinitis, chorioretinal scars or choroidal degeneration, dystrophies, hemorrhage and rupture, or detachment. The patient has Vogt-Koyanagi syndrome. This disease is characterized by bilateral uveitis, dysacousia, meningeal irritation, whitening of patches of hair (poliosis), vitiligo, and retinal detachment. The disease can be initiated by a severe headache, deep orbital pain, vertigo, and nausea. The patient has sustained a penetrating wound to the orbit resulting in the retention of a foreign body in the. Printed on 10/3/2017. Page 2 of 10

3 The patient has disorders of the vitreous body (e.g., vitreous hemorrhage or posterior vitreous detachment). Spots before the s (floaters) and flashing lights (photopsia) can be signs/symptoms of these disorders. The patient has posterior scleritis. Signs and symptoms may include severe pain and inflammation, proptosis, limited ocular movements, and a loss of a portion of the visual field. The patient has degenerative disorders of the globe. The patient has retinoschisis and retinal cysts. Patients may complain of light flashes and floaters. The patient has signs and symptoms of endophthalmitis which may include severe pain, redness, photophobia, and profound loss of vision. The patient has glaucoma or is a glaucoma suspect. This may be evidenced by increased intraocular pressure or progressive cupping of the optic nerve. The patient's medical record must meet the documentation requirements set forth in this policy (see Documentation Requirements). In all instances extended ophthalmoscopy must be medically necessary. It must add information not available from the standard evaluation services and/or information that will demonstrably affect the treatment plan. It is not necessary, for example, to confirm information already available by other means. Summary of Evidence Analysis of Evidence (Rationale for Determination) Back to Top Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims. 012x Hospital Inpatient (Medicare Part B only) 013x Hospital Outpatient 014x Hospital - Laboratory Services Provided to Non-patients 021x Skilled Nursing - Inpatient (Including Medicare Part A) 022x Skilled Nursing - Inpatient (Medicare Part B only) 023x Skilled Nursing - Outpatient 085x Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes. Printed on 10/3/2017. Page 3 of 10

4 0920 Other Diagnostic Services - General Classification CPT/HCPCS Codes Group 1 Paragraph: Group 1 Codes: OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH INTERPRETATION AND REPORT; INITIAL OPHTHALMOSCOPY, EXTENDED, WITH RETINAL DRAWING (EG, FOR RETINAL DETACHMENT, MELANOMA), WITH INTERPRETATION AND REPORT; SUBSEQUENT ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: Group 1 Codes: ICD-10 Codes Description B39.9 Histoplasmosis, unspecified B58.01 Toxoplasma chorioretinitis C C69.22 Malignant neoplasm of unspecified retina - Malignant neoplasm of left retina C C69.32 Malignant neoplasm of unspecified choroid - Malignant neoplasm of left choroid D18.09 Hemangioma of other sites D D31.22 Benign neoplasm of unspecified retina - Benign neoplasm of left retina D D31.32 Benign neoplasm of unspecified choroid - Benign neoplasm of left choroid D33.3 Benign neoplasm of cranial nerves Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy with macular E edema - Diabetes mellitus due to underlying condition with proliferative diabetic retinopathy E without macular edema, E E E E E E E E E E E E E E E E E E E E E E Drug or chemical induced diabetes mellitus with unspecified diabetic retinopathy with macular edema - Drug or chemical induced diabetes mellitus with proliferative diabetic retinopathy without macular edema, Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edema - Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edema Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right - Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right - Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right - Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right - Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right - Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema - Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right - Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right - Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right - Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, Printed on 10/3/2017. Page 4 of 10

5 ICD-10 Codes E E E E E E E E E E E E Description Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right - Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, Other specified diabetes mellitus with unspecified diabetic retinopathy with macular edema - Other specified diabetes mellitus with unspecified diabetic retinopathy without macular edema Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right - Other specified diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right - Other specified diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right - Other specified diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, Other specified diabetes mellitus with proliferative diabetic retinopathy with macular edema, right - Other specified diabetes mellitus with proliferative diabetic retinopathy without macular edema, G45.3 Amaurosis fugax H H05.53 Retained (old) foreign body following penetrating wound of unspecified orbit - Retained (old) foreign body following penetrating wound of bilateral orbits H H Posterior scleritis, right - Posterior scleritis, H H Ophthalmia nodosa, right - Ophthalmia nodosa, H H Unspecified acute and subacute iridocyclitis - Hypopyon, H H Vogt-Koyanagi syndrome, right - Vogt-Koyanagi syndrome, H H Parasitic cyst of iris, ciliary body or anterior chamber, right - Parasitic cyst of iris, ciliary body or anterior chamber, H27.10 Unspecified dislocation of lens H H Subluxation of lens, right - Subluxation of lens, H H Posterior dislocation of lens, right - Posterior dislocation of lens, H H Unspecified focal chorioretinal inflammation, right - Focal chorioretinal inflammation, macular or paramacular, H H Unspecified disseminated chorioretinal inflammation, right - Acute posterior multifocal placoid pigment epitheliopathy, H H30.23 Posterior cyclitis, - Posterior cyclitis, bilateral H H Harada's disease, right - Other chorioretinal inflammations, H H30.93 Unspecified chorioretinal inflammation, - Unspecified chorioretinal inflammation, bilateral H H Unspecified chorioretinal scars, right - Other chorioretinal scars, H H Choroidal degeneration, unspecified, right - Diffuse secondary atrophy of choroid, unspecified H H31.29 Hereditary choroidal dystrophy, unspecified - Other hereditary choroidal dystrophy H H Unspecified choroidal hemorrhage, right - Choroidal rupture, H H Unspecified choroidal detachment, right - Serous choroidal detachment, H32 Chorioretinal disorders in diseases classified elsewhere H H Unspecified retinal detachment with retinal break, right - Total retinal detachment, unspecified H H Unspecified retinoschisis, right - Cyst of ora serrata, Parasitic cyst of retina, right - Parasitic cyst of retina, Printed on 10/3/2017. Page 5 of 10

6 ICD-10 Codes Description H H H H Other retinoschisis and retinal cysts, right - Other retinoschisis and retinal cysts, unspecified H H33.23 Serous retinal detachment, - Serous retinal detachment, bilateral H H Unspecified retinal break, right - Multiple defects of retina without detachment, unspecified H H33.43 Traction detachment of retina, - Traction detachment of retina, bilateral H33.8 Other retinal detachments H H34.9 Transient retinal artery occlusion, - Unspecified retinal vascular occlusion H H35.09 Unspecified background retinopathy - Other intraretinal microvascular abnormalities H H Retinopathy of prematurity, stage 0, right - Retinopathy of prematurity, stage 5, unspecified H H Retrolental fibroplasia, right - Retrolental fibroplasia, H H35.23 Other non-diabetic proliferative retinopathy, - Other non-diabetic proliferative retinopathy, bilateral H H35.33 Unspecified macular degeneration - Angioid streaks of macula H H Macular cyst, hole, or pseudohole, right - Macular cyst, hole, or pseudohole, H H Cystoid macular degeneration, right - Cystoid macular degeneration, H H Drusen (degenerative) of macula, right - Drusen (degenerative) of macula, H H Puckering of macula, right - Puckering of macula, H H Toxic maculopathy, right - Toxic maculopathy, H H Unspecified peripheral retinal degeneration - Secondary vitreoretinal degeneration, H H35.54 Unspecified hereditary retinal dystrophy - Dystrophies primarily involving the retinal pigment epithelium H H35.63 Retinal hemorrhage, - Retinal hemorrhage, bilateral H H Unspecified separation of retinal layers - Hemorrhagic detachment of retinal pigment epithelium, H H35.89 Retinal edema - Other specified retinal disorders H36 Retinal disorders in diseases classified elsewhere H H Preglaucoma, unspecified, right - Primary angle closure without glaucoma damage, H40.10X0 - H Unspecified open-angle glaucoma, stage unspecified - Pigmentary glaucoma,, indeterminate stage H H Capsular glaucoma with pseudoexfoliation of lens, right, stage unspecified - Capsular glaucoma with pseudoexfoliation of lens,, indeterminate stage H H Residual stage of open-angle glaucoma, right - Residual stage of open-angle glaucoma, H40.20X0 - H Unspecified primary angle-closure glaucoma, stage unspecified - Residual stage of angle-closure glaucoma, H40.30X0 - H40.53X4 Glaucoma secondary to trauma,, stage unspecified - Glaucoma secondary to other disorders, bilateral, indeterminate stage H40.60X0 - H40.63X4 Glaucoma secondary to drugs,, stage unspecified - Glaucoma secondary to drugs, bilateral, indeterminate stage H H Glaucoma with increased episcleral venous pressure, right - Aqueous misdirection, unspecified H40.89 Other specified glaucoma Printed on 10/3/2017. Page 6 of 10

7 ICD-10 Codes Description H40.9 Unspecified glaucoma H42 Glaucoma in diseases classified elsewhere H H43.9 Vitreous prolapse, - Unspecified disorder of vitreous body H H Unspecified purulent endophthalmitis, right - Vitreous abscess (chronic), H H44.19 Panuveitis, right - Other endophthalmitis H H44.23 Degenerative myopia, - Degenerative myopia, bilateral H44.2A1 - H44.2E9 Degenerative myopia with choroidal neovascularization, right - Degenerative myopia with other maculopathy, H H Chalcosis, right - Siderosis of, H H Unspecified retained (old) intraocular foreign body, magnetic, right - Unspecified retained (old) intraocular foreign body, magnetic, H H Retained (old) magnetic foreign body in iris or ciliary body, right - Retained (old) magnetic foreign body in iris or ciliary body, H H Retained (old) magnetic foreign body in posterior wall of globe, right - Retained (old) magnetic foreign body in posterior wall of globe, H H Retained (old) magnetic foreign body in vitreous body, right - Retained (old) magnetic foreign body in vitreous body, H H Unspecified retained (old) intraocular foreign body, nonmagnetic, right - Unspecified retained (old) intraocular foreign body, nonmagnetic, H H Retained (nonmagnetic) (old) foreign body in posterior wall of globe, right - Retained (nonmagnetic) (old) foreign body in posterior wall of globe, H H Retained (nonmagnetic) (old) foreign body in vitreous body, right - Retained (nonmagnetic) (old) foreign body in vitreous body, H46.2 Nutritional optic neuropathy H46.3 Toxic optic neuropathy H46.9 Unspecified optic neuritis H H Ischemic optic neuropathy, right - Other disorders of optic nerve, not elsewhere classified, H47.10 Unspecified papilledema H H Unspecified optic atrophy - Other optic atrophy, H H Coloboma of optic disc, right - Other disorders of optic disc, H H Transient visual loss, right - Transient visual loss, H H Sudden visual loss, right - Sudden visual loss, H53.19 Other subjective visual disturbances H H Cataract (lens) fragments in following cataract surgery, right - Cataract (lens) fragments in following cataract surgery, H H Cystoid macular edema following cataract surgery, right - Cystoid macular edema following cataract surgery, Congenital malformation of vitreous humor - Congenital malformation of posterior segment of, Q Q14.9 unspecified Q15.0 Congenital glaucoma Q85.1 Tuberous sclerosis Q85.8 Other phakomatoses, not elsewhere classified Q85.9 Phakomatosis, unspecified Q87.42 Marfan's syndrome with ocular manifestations S05.10XA - S05.12XS Contusion of ball and orbital tissues,, initial encounter - Contusion of ball and orbital tissues, left, sequela Ocular laceration and rupture with prolapse or loss of intraocular tissue,, initial S05.20XA - encounter - Ocular laceration and rupture with prolapse or loss of intraocular tissue, left, S05.22XS sequela Printed on 10/3/2017. Page 7 of 10

8 ICD-10 Codes S05.30XA - S05.32XS S05.50XA - S05.52XS S05.60XA - S05.62XS S05.70XA - S05.72XS S05.8X1A - S05.8X9S S05.90XA - S05.92XS T85.22XA - T85.22XS Description Ocular laceration without prolapse or loss of intraocular tissue,, initial encounter - Ocular laceration without prolapse or loss of intraocular tissue, left, sequela Penetrating wound with foreign body of ball, initial encounter - Penetrating wound with foreign body of left ball, sequela Penetrating wound without foreign body of ball, initial encounter - Penetrating wound without foreign body of left ball, sequela Avulsion of, initial encounter - Avulsion of left, sequela Other injuries of right and orbit, initial encounter - Other injuries of and orbit, sequela Unspecified injury of and orbit, initial encounter - Unspecified injury of left and orbit, sequela Displacement of intraocular lens, initial encounter - Displacement of intraocular lens, sequela ICD-10 Codes that DO NOT Support Medical Necessity ICD-10 Additional Information Back to Top General Information Associated Information Documentation Requirements Medical record documentation (eg, office/progress notes) maintained by the ordering/referring physician must indicate the medical necessity of the extended ophthalmoscopy exam. The medical records must include the following: The complaint or symptomatology necessitating the extended ophthalmoscopy exam Notation that the examined was dilated and the drug used The method of examination (eg, lens, instrument used) A detailed drawing of the retina showing anatomy in the patient as seen at time of examination, including the pathology found and a legible narrative report of the findings An assessment of the change from previous examinations when performing follow-up services (92226) If the provider of the service is other than the ordering/referring physician, that provider must maintain hard copy documentation of the ophthalmoscopy exam results and interpretation, along with copies of the ordering/referring physician s order for the ophthalmoscopy. The physician must state the clinical indication/medical necessity for the ophthalmoscopy in the order for the exam. Documentation in the medical record for a diagnosis of glaucoma (ICD-10 Code H H42, or Q15.0) must include all of the following: a detailed drawing of the optic nerve, documentation of cupping, disc rim, pallor, and slope, and documentation of any surrounding pathology around the optic nerve. Utilization Guidelines It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity. Sources of Information First Coast Service Options, Inc. reference LCD number(s) L28961, L29242, L29373 Yanoff. (2004). Ophthalmology(2nd ed.). St. Louis, MO: Mosby. Printed on 10/3/2017. Page 8 of 10

9 Bibliography Back to Top Revision History Information Revision History Date Revision History Number Revision Number: 5 Revision History Explanation Publication: September 2017 Connection Reason(s) for Change LCR A/B /01/2017 R5 Explanation of Revision: Based on CR (Annual 2018 ICD-10-CM Update) the LCD was revised. Added ICD-10-CM diagnosis codes H44.2A1 H44.2E9. The effective date of this revision is based on date of service. Revisions Due To ICD-10-CM Code Changes 03/23/2017 R4 01/09/2017 R3 10/01/2017: At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination and therefore not all the fields included on the LCD are applicable as noted in this policy. Revision Number: 4 Publication: April 2017 Connection LCR A/B Explanation of Revision: The LCD was revised to add ICD-10-CM diagnosis codes T85.22XA-T85.22XS in the ICD-10 Codes that Support Medical Necessity section of the LCD for CPT codes and The effective date of this revision is for claims processed on or after MM/DD/YYYY, for dates of service on or after 10/01/15. Revision Number: 3 Publication: January 2016 Connection LCR A/B Explanation of Revision: This LCD was revised to include ICD-10 code range E E in the ICD-10 Codes that Support Medical Necessity section of the LCD. The effective date of this revision is for claims processed on or after 01/09/2017, for dates of service on or after 10/01/ /01/2016 R2 Revision Number: 2 Publication: September 2016 Connection LCR A/B Revisions Due To ICD-10-CM Code Changes Revisions Due To ICD-10-CM Code Changes Revisions Due To ICD-10-CM Code Changes Printed on 10/3/2017. Page 9 of 10

10 Revision History Date 10/01/2015 R1 Back to Top Revision History Number Revision History Explanation Explanation of Revision: Based on CR 9677 (Annual 2017 ICD-10-CM Update) the LCD was revised. Revised ICD-10-CM diagnosis code ranges in the ICD-10 Codes that Support Medical Necessity section of the LCD: E E to read E E , E E to read E E , E E to read E E , E E to read E E , E E to read E E , E E to read E E1.3399, E E to read E E , E E to read E E , E E to read E E , E E to read E E , E E to read E E Also, added ICD-10-CM diagnosis codes in the ICD-10 Codes that Support Medical Necessity section of the LCD: E E , E E , and E E In addition, the ICD-10-CM diagnosis codes: E10.321, E11.321, E11.329, and E in the ICD-10 Codes that Support Medical Necessity section of the LCD were deleted. The effective date of this revision is based on date of service. Revision Number: 1 Publication: November 2015 Connection LCR A/B Explanation of revision: This LCD was revised to include ICD-10 code range H H in the ICD-10 Codes that Support Medical Necessity section of the LCD. The effective date of this revision is for claims processed on or after 11/19/2015, for dates of service on or after 10/01/15. Associated Documents Attachments code guide 2017 (PDF - 88 KB ) Reason(s) for Change Revisions Due To ICD-10-CM Code Changes Related Local Coverage Documents Related National Coverage Documents Public Version(s) Updated on 09/22/2017 with effective dates 10/01/ Updated on 03/23/2017 with effective dates 03/23/ /30/2017 Updated on 01/03/2017 with effective dates 01/09/ /22/2017 Updated on 10/10/2016 with effective dates 10/01/ /08/2017 Updated on 11/13/2015 with effective dates 10/01/ /30/2016 Updated on 07/01/2014 with effective dates 10/01/ Updated on 04/04/2014 with effective dates 10/01/ Back to Top Keywords Read the LCD Disclaimer Back to Top Printed on 10/3/2017. Page 10 of 10