LABORATORY SERVICES CSHCN SERVICES PROGRAM PROVIDER MANUAL

Transcription

1 LABORATORY SERVICES CSHCN SERVICES PROGRAM PROVIDER MANUAL JUNE 2018

2 CSHCN PROVIDER PROCEDURES MANUAL JUNE 2018 LABORATORY SERVICES Table of Contents 25.1 Enrollment Clinical Laboratory Improvement Amendments (CLIA) of Waiver and Physician-Performed Microscopy Procedure (PPMP) Certificates Benefits, Limitations, and Authorization Requirements Hospital Laboratory Services Independent Laboratory Services Physician-Owned Laboratory Services Other Physician Laboratory-Related Services Clinical Pathology Services Other Laboratory Procedures Drug Testing and Therapeutic Drug Assays Cytogenetics Testing Genetic Testing for Colorectal Cancer Authorization Requirements Familial Adenomatous Polyposis (FAP) Hereditary Nonpolyposis Colorectal Cancer (HNPCC) Genetic Testing for Hereditary Breast and Ovarian Cancers Authorization Requirements Cytopathology of Vaginal, Cervical, and Uterine Sites Cytopathology Studies Other Than Vaginal, Cervical, or Uterine Evocative and Suppression Testing Helicobacter pylori (H. pylori) Hematology and Coagulation Microbiology Zika Virus Testing Human Immunodeficiency Virus (HIV) Drug Resistance Testing Organ or Disease-Oriented Panels Urinalysis and Chemistry Other Laboratory Services Repeated Procedures Modifier Receiving Labs and Lab Handling Fees Claims Information Modifiers To Use When Billing Laboratory Procedures Reimbursement Clinical Laboratory Fee Schedule One-day Payment Window Reimbursement Guidelines TMHP-CSHCN Services Program Contact Center CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 2

3 25.1 Enrollment To enroll in the CSHCN Services Program, laboratories must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, be certified according to the Clinical Laboratory Improvement Amendments (CLIA) of 1988, and comply with all applicable state laws and requirements. Out-of-state laboratory providers must meet all of these conditions and be located in the United States within 50 miles of the Texas state border. The following laboratories are eligible for enrollment in the CSHCN Services Program: A physician s office Meets staff, equipment, and testing capability standards for certification by the Department of State Health Services (DSHS) Medicare-certified and enrolled as a Medicaid provider Providers must also submit a current copy of their permit or license and a copy of the approval letter from DSHS Note: If a physician performs more than 100 laboratory tests per year for other providers in their laboratory, the laboratory must be certified by Medicare, and the provider must enroll as an independent laboratory with TMHP. A hospital laboratory for inpatient, outpatient, and nonpatient client claims (a hospital nonpatient is one who is not registered as an inpatient or an outpatient but whose laboratory services are performed by the hospital laboratory) Meets staff, equipment, and testing capability standards for certification by the Department of State Health Services (DSHS) Medicare-certified and enrolled as a Medicaid provider Providers must also submit a current copy of their permit or license and a copy of the approval letter from DSHS An independent (freestanding) laboratory An independent (freestanding) laboratory enrolled in the CSHCN Services Program is defined as a facility that meets all of the following criteria: Facility independent from a physician s office, ASC, or hospital Meets staff, equipment, and testing capability standards for certification by the Department of State Health Services (DSHS) Medicare-certified and enrolled as a Medicaid provider Providers must also submit a current copy of their permit or license and a copy of the approval letter from DSHS Important: CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid. By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 25 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371. CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 3

4 CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 25 TAC 38.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession, as well as those required by the CSHCN Services Program and Texas Medicaid. Refer to: The CMS website at for information about procedure codes and modifier QW requirements. The CSHCN Services Program follows the Medicare categorization of tests for CLIA certificate-holders. Section 2.1, Provider Enrollment in Chapter 2, Provider Enrollment and Responsibilities for more detailed information about CSHCN Services Program provider enrollment procedures Clinical Laboratory Improvement Amendments (CLIA) of 1988 To be eligible for reimbursement by the CSHCN Services Program, all providers performing laboratory tests must: Enroll with the Centers for Medicare & Medicaid Services (CMS). Receive a CLIA registration and certification number by contacting DSHS at or access CLIA information at or at Submit CLIA applications to the following address: Texas Department of State Health Services Patient Quality Care, MC-1979/E West 49th Street Austin, TX Notify TMHP of the assigned CLIA number by fax at or by mail at the following address: Texas Medicaid & Healthcare Partnership Attn: Provider Enrollment PO Box Austin, TX CMS implemented CLIA. The CLIA regulations were published in the February 28, 1992, Federal Register and have been amended several times since. Copies of the CLIA rules and regulations are located at the CMS website at These regulations concern all laboratory testing used for the assessment of human health or the diagnosis, prevention, or treatment of disease. CLIA regulations set standards designed to improve quality in all laboratory testing and include specifications for quality control (QC), quality assurance (QA), patient test management, personnel, and proficiency testing. Under CLIA 88, all clinical laboratories (including those located in physician s offices), regardless of location, size, or type of laboratory must meet standards based on the complexity of the test(s) they perform. Important: The CSHCN Services Program monitors claims submitted by clinical laboratories for CLIA numbers. Claims submitted for laboratory services are denied if there is not a CLIA number on file with the CSHCN Services Program. CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 4

5 Refer to: The CMS website at for information about procedure codes and modifier QW requirements. The CSHCN Services Program follows the Medicare categorization of tests for CLIA certificate-holders Waiver and Physician-Performed Microscopy Procedure (PPMP) Certificates Providers are responsible for practicing within the limits of their certificates and maintaining awareness of the most current information regarding enforcement of CLIA provisions. Note: Providers may refer to the CMS website at _of_tests.asp for a list of waived test and provider-performed microscopy procedures (PPMP) procedure codes. CSHCN Services Program bills must accurately reflect only those services authorized by CLIA regulations Benefits, Limitations, and Authorization Requirements Authorization is not required for laboratory services. The CSHCN Services Program may reimburse the following laboratories for services when the laboratory is certified according to the CLIA regulations and enrolled in the CSHCN Services Program: A hospital laboratory for outpatient and nonpatient client claims A physician s office An independent laboratory Providers must bill the most specific diagnosis and procedure codes that describes the services provided. Laboratory tests generally performed as a panel and performed on the same day by the same provider, must be billed as a panel, regardless of the method used to perform the tests (automated or manual). The CSHCN Services Program pays only the amount allowed for the total component for the same procedure, same client, same date of service, and any provider. Providers who perform both the technical service and interpretation must bill for the total component. Providers who perform only the technical service must bill for the technical component. Providers who perform only the interpretation must bill for the interpretation component. Claims filed in excess of the amount allowed for the total component for the same procedure, same dates of service, same client, any provider, are denied. Claims are paid based on the order in which they are received. For example, if a claim is received for the total component, and if payment has been made for the technical and interpretation component for the same procedure, same dates of service, same client, from any provider, the claim for the total component is denied as previously paid to another provider. The same is true if a total component is paid and subsequent claims are received for the individual components Hospital Laboratory Services Hospital laboratory services are a benefit for inpatient, outpatient, and nonpatient clients. A hospital nonpatient is one who is not registered as an inpatient or an outpatient but whose laboratory services are performed by the hospital laboratory. Outpatient and nonpatient claims for laboratory services must reflect only tests actually performed by the hospital laboratory. However, hospital laboratories may bill for all of the tests performed on a specimen even if a portion of the tests are done by another laboratory on referral from the hospital CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 5

6 submitting the claim. If the specimen is collected by venipuncture or catheterization, hospitals may bill procedure code for collecting and forwarding a specimen to a receiving laboratory. Only one handling fee may be charged per day, per client, unless specimens are sent to two or more laboratories. In order to bill a handling fee, the receiving laboratory s name and address and unique Texas provider identifier (TPI) number must be included on the claim in Blocks 17 and 17B. In order to bill nonpatient claims for laboratory services, the complete name and address and unique TPI of the attending, ordering, designated, or performing (freestanding ASCs only) provider must be included on the claim in Blocks 17 and 17B Independent Laboratory Services Independent laboratories that provide laboratory tests to clients registered as hospital inpatients or hospital outpatients are not directly reimbursed. Reimbursement must be obtained from the hospital. An independent laboratory that forwards a specimen to another laboratory without performing any tests on that specimen may not bill for laboratory tests. An independent laboratory may bill the CSHCN Services Program for tests referred to another laboratory (independent or hospital) only if the independent laboratory performs at least one test and forwards a portion of the same specimen to another laboratory to have one or more tests performed. In this instance, the referring laboratory may bill for tests it performs and all tests the receiving laboratory performs on the specimen. In both instances, an independent laboratory that forwards a specimen to another laboratory may bill a handling fee (procedure code 99001) for collection and forwarding the specimen if the specimen is collected by venipuncture or catheterization. In order to bill a handling fee, the receiving laboratory s name and address and unique TPI number must be included on the claim in Blocks 17 and 17B. The CSHCN Services Program covers professional and technical services that an independent laboratory is certified by Medicare to perform Physician-Owned Laboratory Services The CSHCN Services Program reimburses laboratory services ordered by a physician and provided under the provider s personal supervision in a setting other than an inpatient or outpatient hospital Other Physician Laboratory-Related Services Physicians may only bill for those laboratory tests that are actually performed in their offices. Clinical laboratory services performed in a physician s office may be reimbursed at 60 percent of the prevailing charge levels. A laboratory handling fee (procedure code 99000) may be billed if the specimen is obtained by venipuncture or catheterization and sent to an outside laboratory. Only one lab handling fee per day, per client, may be billed, unless multiple specimens are obtained and sent to different laboratories. In order to bill a handling fee, the receiving laboratory s name and address and unique TPI number must be included on the claim in Blocks 17 and 17B. Laboratory services must be documented in clients medical records as medically necessary and reference an appropriate diagnosis. Laboratory tests generally performed as a panel (chemistries, complete blood counts [CBCs], or urinalyses [UAs]) and performed on the same day by the same provider must be billed as a panel regardless of the method used to perform the test. Interpretation of laboratory tests for the physician s patients in the hospital, office, or emergency rooms are considered part of the physician s professional services and should not be billed separately. CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 6

7 Clinical Pathology Services Clinical pathology consultations are a benefit when performed by a clinical pathologist or geneticist. A geneticist may submit claims for procedure codes and using their physician provider identifier. Independent laboratories may submit claims for procedure codes and when services are performed in the independent laboratory setting. Routine conversations between a consultant and an attending physician about test orders or results are not considered consultations. The service does not qualify as a consultation if the information could ordinarily be furnished by a nonphysician laboratory specialist. Claims for clinical pathology consultations must be submitted with the following documentation: The name and address, or the CSHCN Services Program provider identifier for the physician requesting the consultation, must be included on the claim. The NPI of the physician requesting the consultation should also be included, if known. A copy of the written narrative report describing the consultation findings. Documented interaction that clearly outlines that the consultant interpreted the test results and made specific recommendations to the ordering physician. Important: If the claim does not include all of this information, the clinical pathology consultation will be denied Other Laboratory Procedures Procedure Codes 1 per lifetime S3840 S3841 S3842 S Drug Testing and Therapeutic Drug Assays The following procedure codes for drug testing and therapeutic drug assays are benefits of the CSHCN Services Program: Procedure Codes Drug Testing 80305^ G0480 G0481 G0482 G0483 G0659 Therapeutic Drug Assays ^ ^ QW Modifier CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 7

8 Procedure Codes ^ QW Modifier Note: The procedure codes above do not require prior authorization. Procedure codes G0480, G0481, G0482, G0483, and G0659 are limited to once per day by any provider. The following CPT drug assay procedure codes will deny when billed on the same date of service, by the same provider with the corresponding HCPCS drug assay procedure codes identified by an "X" in the following table: CPT Drug Assay Procedure Codes to HCPCS Procedure Codes limitations G0480 G0481 G0482 G0483 G ^ X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X X - The "8000" CPT procedure code will be denied if billed with the HCPCS "G" procedure code indicated with an "X". ^QW Modifier CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 8

9 CPT Drug Assay Procedure Codes to HCPCS Procedure Codes limitations X X X X - The "8000" CPT procedure code will be denied if billed with the HCPCS "G" procedure code indicated with an "X". ^QW Modifier Cytogenetics Testing When billed with an appropriate diagnosis code, cytogenetics testing procedure codes have the following limitations: Procedure Code Quantity Allowed Tissue Culture per day, any provider per day, any provider per day, any provider per day, any provider per day, any provider per day, any provider per day, any provider Chromosome Analysis per day, any provider per day, any provider per day, any provider per day, any provider per day, any provider per day, any provider per day, any provider per day, any provider per day, any provider per day, any provider per day, any provider Molecular Cytogenetics per provider, per day per provider, per day per provider, per day per provider, per day per provider, per day Providers must bill procedure code for the interpretation and report of cytogenetics testing. CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 9

10 Reimbursement for cytogenetics testing is limited to the following diagnosis codes: C8280 C8281 C8282 C8283 C8284 C8285 C8286 C8287 C8288 C8289 C8291 C8292 C8293 C8294 C8295 C8296 C8297 C8298 C8299 C8310 C8311 C8312 C8313 C8314 C8315 C8316 C8317 C8318 C8319 C8380 C8381 C8382 C8383 C8384 C8385 C8386 C8387 Other types of follicular lymphoma, unspecified site Other types of follicular lymphoma, lymph nodes of head, face, and neck Other types of follicular lymphoma, intrathoracic lymph nodes Other types of follicular lymphoma, intra-abdominal lymph nodes Other types of follicular lymphoma, lymph nodes of axilla and upper limb Other types of follicular lymphoma, lymph nodes of inguinal region and lower limb Other types of follicular lymphoma, intrapelvic lymph nodes Other types of follicular lymphoma, spleen Other types of follicular lymphoma, lymph nodes of multiple sites Other types of follicular lymphoma, extranodal and solid organ sites Follicular lymphoma, unspecified, lymph nodes of head, face, and neck Follicular lymphoma, unspecified, intrathoracic lymph nodes Follicular lymphoma, unspecified, intra-abdominal lymph nodes Follicular lymphoma, unspecified, lymph nodes of axilla and upper limb Follicular lymphoma, unspecified, lymph nodes of inguinal region and lower limb Follicular lymphoma, unspecified, intrapelvic lymph nodes Follicular lymphoma, unspecified, spleen Follicular lymphoma, unspecified, lymph nodes of multiple sites Follicular lymphoma, unspecified, extranodal and solid organ sites Mantle cell lymphoma, unspecified site Mantle cell lymphoma, lymph nodes of head, face, and neck Mantle cell lymphoma, intrathoracic lymph nodes Mantle cell lymphoma, intra-abdominal lymph nodes Mantle cell lymphoma, lymph nodes of axilla and upper limb Mantle cell lymphoma, lymph nodes of inguinal region and lower limb Mantle cell lymphoma, intrapelvic lymph nodes Mantle cell lymphoma, spleen Mantle cell lymphoma, lymph nodes of multiple sites Mantle cell lymphoma, extranodal and solid organ sites Other non-follicular lymphoma, unspecified site Other non-follicular lymphoma, lymph nodes of head, face, and neck Other non-follicular lymphoma, intrathoracic lymph nodes Other non-follicular lymphoma, intra-abdominal lymph nodes Other non-follicular lymphoma, lymph nodes of axilla and upper limb Other non-follicular lymphoma, lymph nodes of inguinal region and lower limb Other non-follicular lymphoma, intrapelvic lymph nodes Other non-follicular lymphoma, spleen CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 10

11 C8388 C8389 C8440 C8441 C8442 C8443 C8444 C8445 C8446 C8447 C8448 C8449 C8461 C8462 C8463 C8464 C8465 C8466 C8467 C8468 C8469 C8471 C8472 C8473 C8474 C8475 C8476 C8477 C8478 C8479 C8581 C8582 C8584 Other non-follicular lymphoma, lymph nodes of multiple sites Other non-follicular lymphoma, extranodal and solid organ sites Peripheral T-cell lymphoma, not classified, unspecified site Peripheral T-cell lymphoma, not classified, lymph nodes of head, face, and neck Peripheral T-cell lymphoma, not classified, intrathoracic lymph nodes Peripheral T-cell lymphoma, not classified, intra-abdominal lymph nodes Peripheral T-cell lymphoma, not classified, lymph nodes of axilla and upper limb Peripheral T-cell lymphoma, not classified, lymph nodes of inguinal region and lower limb Peripheral T-cell lymphoma, not classified, intrapelvic lymph nodes Peripheral T-cell lymphoma, not classified, spleen Peripheral T-cell lymphoma, not classified, lymph nodes of multiple sites Peripheral T-cell lymphoma, not classified, extranodal and solid organ sites Anaplastic large cell lymphoma, ALK-positive, lymph nodes of head, face, and neck Anaplastic large cell lymphoma, ALK-positive, intrathoracic lymph nodes Anaplastic large cell lymphoma, ALK-positive, intra-abdominal lymph nodes Anaplastic large cell lymphoma, ALK-positive, lymph nodes of axilla and upper limb Anaplastic large cell lymphoma, ALK-positive, lymph nodes of inguinal region and lower limb Anaplastic large cell lymphoma, ALK-positive, intrapelvic lymph nodes Anaplastic large cell lymphoma, ALK-positive, spleen Anaplastic large cell lymphoma, ALK-positive, lymph nodes of multiple sites Anaplastic large cell lymphoma, ALK-positive, extranodal and solid organ sites Anaplastic large cell lymphoma, ALK-negative, lymph nodes of head, face, and neck Anaplastic large cell lymphoma, ALK-negative, intrathoracic lymph nodes Anaplastic large cell lymphoma, ALK-negative, intra-abdominal lymph nodes Anaplastic large cell lymphoma, ALK-negative, lymph nodes of axilla and upper limb Anaplastic large cell lymphoma, ALK-negative, lymph nodes of inguinal region and lower limb Anaplastic large cell lymphoma, ALK-negative, intrapelvic lymph nodes Anaplastic large cell lymphoma, ALK-negative, spleen Anaplastic large cell lymphoma, ALK-negative, lymph nodes of multiple sites Anaplastic large cell lymphoma, ALK-negative, extranodal and solid organ sites Other specified types of non-hodgkin lymphoma, lymph nodes of head, face, and neck Other specified types of non-hodgkin lymphoma, intrathoracic lymph nodes Other specified types of non-hodgkin lymphoma, lymph nodes of axilla and upper limb CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 11

12 C8585 C8586 C8587 C8588 C8589 C884 C888 C9012 C9100 C9101 C9102 C9110 C9111 C9112 C9190 C9191 C9192 C91Z0 C91Z1 C91Z2 C9200 C9201 C9202 C9210 C9211 C9212 C9220 C9221 C9222 C9230 C9231 C9232 C9240 C9241 C9242 C9250 C9251 Other specified types of non-hodgkin lymphoma, lymph nodes of inguinal region and lower limb Other specified types of non-hodgkin lymphoma, intrapelvic lymph nodes Other specified types of non-hodgkin lymphoma, spleen Other specified types of non-hodgkin lymphoma, lymph nodes of multiple sites Other specified types of non-hodgkin lymphoma, extranodal and solid organ sites Extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue [MALT-lymphoma] Other malignant immunoproliferative diseases Plasma cell leukemia in relapse Acute lymphoblastic leukemia not having achieved remission Acute lymphoblastic leukemia, in remission Acute lymphoblastic leukemia, in relapse Chronic lymphocytic leukemia of B-cell type not having achieved remission Chronic lymphocytic leukemia of B-cell type in remission Chronic lymphocytic leukemia of B-cell type in relapse Lymphoid leukemia, unspecified not having achieved remission Lymphoid leukemia, unspecified, in remission Lymphoid leukemia, unspecified, in relapse Other lymphoid leukemia not having achieved remission Other lymphoid leukemia, in remission Other lymphoid leukemia, in relapse Acute myeloblastic leukemia, not having achieved remission Acute myeloblastic leukemia, in remission Acute myeloblastic leukemia, in relapse Chronic myeloid leukemia, BCR/ABL-positive, not having achieved remission Chronic myeloid leukemia, BCR/ABL-positive, in remission Chronic myeloid leukemia, BCR/ABL-positive, in relapse Atypical chronic myeloid leukemia, BCR/ABL-negative, not having achieved remission Atypical chronic myeloid leukemia, BCR/ABL-negative, in remission Atypical chronic myeloid leukemia, BCR/ABL-negative, in relapse Myeloid sarcoma, not having achieved remission Myeloid sarcoma, in remission Myeloid sarcoma, in relapse Acute promyelocytic leukemia, not having achieved remission Acute promyelocytic leukemia, in remission Acute promyelocytic leukemia, in relapse Acute myelomonocytic leukemia, not having achieved remission Acute myelomonocytic leukemia, in remission CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 12

13 C9252 C9260 C9261 C9262 C9290 C9291 C9292 C92A0 C92A1 C92A2 C92Z0 C92Z1 C92Z2 C9300 C9301 C9302 C9310 C9311 C9312 C9330 C9331 C9390 C9391 C9392 C93Z0 C93Z1 C93Z2 C9400 C9401 C9402 C9420 C9421 C9422 C9430 C9431 C9432 C9480 C9481 C9482 Acute myelomonocytic leukemia, in relapse Acute myeloid leukemia with 11q23-abnormality not having achieved remission Acute myeloid leukemia with 11q23-abnormality in remission Acute myeloid leukemia with 11q23-abnormality in relapse Myeloid leukemia, unspecified, not having achieved remission Myeloid leukemia, unspecified in remission Myeloid leukemia, unspecified in relapse Acute myeloid leukemia with multilineage dysplasia, not having achieved remission Acute myeloid leukemia with multilineage dysplasia, in remission Acute myeloid leukemia with multilineage dysplasia, in relapse Other myeloid leukemia not having achieved remission Other myeloid leukemia, in remission Other myeloid leukemia, in relapse Acute monoblastic/monocytic leukemia, not having achieved remission Acute monoblastic/monocytic leukemia, in remission Acute monoblastic/monocytic leukemia, in relapse Chronic myelomonocytic leukemia not having achieved remission Chronic myelomonocytic leukemia, in remission Chronic myelomonocytic leukemia, in relapse Juvenile myelomonocytic leukemia, not having achieved remission Juvenile myelomonocytic leukemia, in remission Monocytic leukemia, unspecified, not having achieved remission Monocytic leukemia, unspecified in remission Monocytic leukemia, unspecified in relapse Other monocytic leukemia, not having achieved remission Other monocytic leukemia, in remission Other monocytic leukemia, in relapse Acute erythroid leukemia, not having achieved remission Acute erythroid leukemia, in remission Acute erythroid leukemia, in relapse Acute megakaryoblastic leukemia not having achieved remission Acute megakaryoblastic leukemia, in remission Acute megakaryoblastic leukemia, in relapse Mast cell leukemia not having achieved remission Mast cell leukemia, in remission Mast cell leukemia, in relapse Other specified leukemias not having achieved remission Other specified leukemias, in remission Other specified leukemias, in relapse CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 13

14 C9500 C9501 C9502 C9510 C9511 C9512 C9590 C9591 C9592 D45 D821 E230 E291 E300 E343 E83110 E8359 F70 F71 F72 F73 F78 F800 F801 F802 F804 F8089 F810 F812 F8181 F8189 F819 F82 F840 F88 F900 F901 F902 F908 H0589 Acute leukemia of unspecified cell type not having achieved remission Acute leukemia of unspecified cell type, in remission Acute leukemia of unspecified cell type, in relapse Chronic leukemia of unspecified cell type not having achieved remission Chronic leukemia of unspecified cell type, in remission Chronic leukemia of unspecified cell type, in relapse Leukemia, unspecified not having achieved remission Leukemia, unspecified, in remission Leukemia, unspecified, in relapse Polycythemia vera Di George's syndrome Hypopituitarism Testicular hypofunction Delayed puberty Short stature due to endocrine disorder Hereditary hemochromatosis Other disorders of calcium metabolism Mild intellectual disabilities Moderate intellectual disabilities Severe intellectual disabilities Profound intellectual disabilities Other intellectual disabilities Phonological disorder Expressive language disorder Mixed receptive-expressive language disorder Speech and language development delay due to hearing loss Other developmental disorders of speech and language Specific reading disorder Mathematics disorder Disorder of written expression Other developmental disorders of scholastic skills Developmental disorder of scholastic skills, unspecified Specific developmental disorder of motor function Autistic disorder Other disorders of psychological development Attention-deficit hyperactivity disorder, predominantly inattentive type Attention-deficit hyperactivity disorder, predominantly hyperactive type Attention-deficit hyperactivity disorder, combined type Attention-deficit hyperactivity disorder, other type Other disorders of orbit CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 14

15 H9325 I77810 I77811 I77812 I77819 M2600 M2601 M2602 M2603 M2604 M2605 M2606 M2607 M2609 N6482 P2930 P2938 Q000 Q001 Q002 Q010 Q011 Q012 Q018 Q02 Q030 Q031 Q038 Q040 Q041 Q042 Q045 Q046 Q048 Q050 Q051 Q052 Q054 Q055 Q056 Central auditory processing disorder Thoracic aortic ectasia Abdominal aortic ectasia Thoracoabdominal aortic ectasia Aortic ectasia, unspecified site Unspecified anomaly of jaw size Maxillary hyperplasia Maxillary hypoplasia Mandibular hyperplasia Mandibular hypoplasia Macrogenia Microgenia Excessive tuberosity of jaw Other specified anomalies of jaw size Hypoplasia of breast Pulmonary hypertension of newborn Other persistent fetal circulation Anencephaly Craniorachischisis Iniencephaly Frontal encephalocele Nasofrontal encephalocele Occipital encephalocele Encephalocele of other sites Microcephaly Malformations of aqueduct of Sylvius Atresia of foramina of Magendie and Luschka Other congenital hydrocephalus Congenital malformations of corpus callosum Arhinencephaly Holoprosencephaly Megalencephaly Congenital cerebral cysts Other specified congenital malformations of brain Cervical spina bifida with hydrocephalus Thoracic spina bifida with hydrocephalus Lumbar spina bifida with hydrocephalus Unspecified spina bifida with hydrocephalus Cervical spina bifida without hydrocephalus Thoracic spina bifida without hydrocephalus CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 15

16 Q057 Q058 Q062 Q064 Q068 Q0701 Q0702 Q0703 Q078 Q079 Q100 Q101 Q102 Q103 Q104 Q106 Q107 Q110 Q111 Q112 Q113 Q120 Q121 Q123 Q124 Q128 Q129 Q130 Q131 Q132 Q133 Q134 Q135 Q1381 Q1389 Q140 Q141 Q142 Q143 Q148 Lumbar spina bifida without hydrocephalus Sacral spina bifida without hydrocephalus Diastematomyelia Hydromyelia Other specified congenital malformations of spinal cord Arnold-Chiari syndrome with spina bifida Arnold-Chiari syndrome with hydrocephalus Arnold-Chiari syndrome with spina bifida and hydrocephalus Other specified congenital malformations of nervous system Congenital malformation of nervous system, unspecified Congenital ptosis Congenital ectropion Congenital entropion Other congenital malformations of eyelid Absence and agenesis of lacrimal apparatus Other congenital malformations of lacrimal apparatus Congenital malformation of orbit Cystic eyeball Other anophthalmos Microphthalmos Macrophthalmos Congenital cataract Congenital displaced lens Congenital aphakia Spherophakia Other congenital lens malformations Congenital lens malformation, unspecified Coloboma of iris Absence of iris Other congenital malformations of iris Congenital corneal opacity Other congenital corneal malformations Blue sclera Rieger's anomaly Other congenital malformations of anterior segment of eye Congenital malformation of vitreous humor Congenital malformation of retina Congenital malformation of optic disc Congenital malformation of choroid Other congenital malformations of posterior segment of eye CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 16

17 Q150 Q158 Q159 Q160 Q161 Q162 Q163 Q164 Q165 Q169 Q170 Q171 Q172 Q173 Q174 Q175 Q178 Q179 Q180 Q181 Q182 Q183 Q184 Q185 Q186 Q187 Q188 Q189 Q200 Q201 Q202 Q203 Q204 Q205 Q206 Q208 Q209 Q210 Q211 Q212 Congenital glaucoma Other specified congenital malformations of eye Congenital malformation of eye, unspecified Congenital absence of (ear) auricle Congenital absence, atresia and stricture of auditory canal (external) Absence of eustachian tube Congenital malformation of ear ossicles Other congenital malformations of middle ear Congenital malformation of inner ear Congenital malformation of ear causing impairment of hearing, unspecified Accessory auricle Macrotia Microtia Other misshapen ear Misplaced ear Prominent ear Other specified congenital malformations of ear Congenital malformation of ear, unspecified Sinus, fistula and cyst of branchial cleft Preauricular sinus and cyst Other branchial cleft malformations Webbing of neck Macrostomia Microstomia Macrocheilia Microcheilia Other specified congenital malformations of face and neck Congenital malformation of face and neck, unspecified Common arterial trunk Double outlet right ventricle Double outlet left ventricle Discordant ventriculoarterial connection Double inlet ventricle Discordant atrioventricular connection Isomerism of atrial appendages Other congenital malformations of cardiac chambers and connections Congenital malformation of cardiac chambers and connections, unspecified Ventricular septal defect Atrial septal defect Atrioventricular septal defect CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 17

18 Q213 Q214 Q218 Q219 Q220 Q221 Q222 Q223 Q224 Q225 Q228 Q230 Q231 Q232 Q233 Q234 Q238 Q240 Q241 Q242 Q243 Q244 Q245 Q246 Q248 Q249 Q250 Q251 Q2521 Q2529 Q253 Q2540 Q2541 Q2542 Q2543 Q2544 Q2545 Q2546 Q2547 Q2548 Tetralogy of Fallot Aortopulmonary septal defect Other congenital malformations of cardiac septa Congenital malformation of cardiac septum, unspecified Pulmonary valve atresia Congenital pulmonary valve stenosis Congenital pulmonary valve insufficiency Other congenital malformations of pulmonary valve Congenital tricuspid stenosis Ebstein's anomaly Other congenital malformations of tricuspid valve Congenital stenosis of aortic valve Congenital insufficiency of aortic valve Congenital mitral stenosis Congenital mitral insufficiency Hypoplastic left heart syndrome Other congenital malformations of aortic and mitral valves Dextrocardia Levocardia Cor triatriatum Pulmonary infundibular stenosis Congenital subaortic stenosis Malformation of coronary vessels Congenital heart block Other specified congenital malformations of heart Congenital malformation of heart, unspecified Patent ductus arteriosus Coarctation of aorta Interruption of aortic arch Other atresia of aorta Supravalvular aortic stenosis Congenital malformation of aorta unspecified Absence and aplasia of aorta Hypoplasia of aorta Congenital aneurysm of aorta Congenital dilation of aorta Double aortic arch Tortuous aortic arch Right aortic arch Anomalous origin of subclavian artery CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 18

19 Q2549 Q2572 Q259 Q260 Q261 Q262 Q263 Q265 Q266 Q268 Q269 Q270 Q271 Q272 Q2730 Q2731 Q2732 Q2733 Q2734 Q274 Q278 Q279 Q280 Q281 Q282 Q283 Q288 Q289 Q300 Q301 Q302 Q303 Q308 Q309 Q310 Q311 Q312 Q313 Q315 Q318 Other congenital malformations of aorta Congenital pulmonary arteriovenous malformation Congenital malformation of great arteries, unspecified Congenital stenosis of vena cava Persistent left superior vena cava Total anomalous pulmonary venous connection Partial anomalous pulmonary venous connection Anomalous portal venous connection Portal vein-hepatic artery fistula Other congenital malformations of great veins Congenital malformation of great vein, unspecified Congenital absence and hypoplasia of umbilical artery Congenital renal artery stenosis Other congenital malformations of renal artery Arteriovenous malformation, site unspecified Arteriovenous malformation of vessel of upper limb Arteriovenous malformation of vessel of lower limb Arteriovenous malformation of digestive system vessel Arteriovenous malformation of renal vessel Congenital phlebectasia Other specified congenital malformations of peripheral vascular system Congenital malformation of peripheral vascular system, unspecified Arteriovenous malformation of precerebral vessels Other malformations of precerebral vessels Arteriovenous malformation of cerebral vessels Other malformations of cerebral vessels Other specified congenital malformations of circulatory system Congenital malformation of circulatory system, unspecified Choanal atresia Agenesis and underdevelopment of nose Fissured, notched and cleft nose Congenital perforated nasal septum Other congenital malformations of nose Congenital malformation of nose, unspecified Web of larynx Congenital subglottic stenosis Laryngeal hypoplasia Laryngocele Congenital laryngomalacia Other congenital malformations of larynx CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 19

20 Q320 Q321 Q322 Q323 Q324 Q330 Q331 Q332 Q333 Q334 Q335 Q336 Q338 Q339 Q348 Q349 Q351 Q353 Q359 Q360 Q369 Q370 Q371 Q372 Q373 Q374 Q375 Q380 Q381 Q382 Q383 Q384 Q385 Q386 Q387 Q388 Q391 Q392 Q393 Q394 Congenital tracheomalacia Other congenital malformations of trachea Congenital bronchomalacia Congenital stenosis of bronchus Other congenital malformations of bronchus Congenital cystic lung Accessory lobe of lung Sequestration of lung Agenesis of lung Congenital bronchiectasis Ectopic tissue in lung Congenital hypoplasia and dysplasia of lung Other congenital malformations of lung Congenital malformation of lung, unspecified Other specified congenital malformations of respiratory system Congenital malformation of respiratory system, unspecified Cleft hard palate Cleft soft palate Cleft palate, unspecified Cleft lip, bilateral Cleft lip, unilateral Cleft hard palate with bilateral cleft lip Cleft hard palate with unilateral cleft lip Cleft soft palate with bilateral cleft lip Cleft soft palate with unilateral cleft lip Cleft hard and soft palate with bilateral cleft lip Cleft hard and soft palate with unilateral cleft lip Congenital malformations of lips, not elsewhere classified Ankyloglossia Macroglossia Other congenital malformations of tongue Congenital malformations of salivary glands and ducts Congenital malformations of palate, not elsewhere classified Other congenital malformations of mouth Congenital pharyngeal pouch Other congenital malformations of pharynx Atresia of esophagus with tracheo-esophageal fistula Congenital tracheo-esophageal fistula without atresia Congenital stenosis and stricture of esophagus Esophageal web CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 20

21 Q395 Q396 Q398 Q400 Q401 Q402 Q408 Q409 Q410 Q411 Q412 Q419 Q420 Q421 Q422 Q423 Q428 Q430 Q431 Q432 Q433 Q434 Q435 Q437 Q438 Q440 Q441 Q442 Q443 Q444 Q445 Q446 Q447 Q450 Q451 Q452 Q453 Q458 Q459 Q5001 Congenital dilatation of esophagus Congenital diverticulum of esophagus Other congenital malformations of esophagus Congenital hypertrophic pyloric stenosis Congenital hiatus hernia Other specified congenital malformations of stomach Other specified congenital malformations of upper alimentary tract Congenital malformation of upper alimentary tract, unspecified Congenital absence, atresia and stenosis of duodenum Congenital absence, atresia and stenosis of jejunum Congenital absence, atresia and stenosis of ileum Congenital absence, atresia and stenosis of small intestine, part unspecified Congenital absence, atresia and stenosis of rectum with fistula Congenital absence, atresia and stenosis of rectum without fistula Congenital absence, atresia and stenosis of anus with fistula Congenital absence, atresia and stenosis of anus without fistula Congenital absence, atresia and stenosis of other parts of large intestine Meckel's diverticulum (displaced) (hypertrophic) Hirschsprung's disease Other congenital functional disorders of colon Congenital malformations of intestinal fixation Duplication of intestine Ectopic anus Persistent cloaca Other specified congenital malformations of intestine Agenesis, aplasia and hypoplasia of gallbladder Other congenital malformations of gallbladder Atresia of bile ducts Congenital stenosis and stricture of bile ducts Choledochal cyst Other congenital malformations of bile ducts Cystic disease of liver Other congenital malformations of liver Agenesis, aplasia and hypoplasia of pancreas Annular pancreas Congenital pancreatic cyst Other congenital malformations of pancreas and pancreatic duct Other specified congenital malformations of digestive system Congenital malformation of digestive system, unspecified Congenital absence of ovary, unilateral CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 21

22 Q5002 Q501 Q502 Q5031 Q5032 Q5039 Q504 Q505 Q506 Q510 Q5110 Q5111 Q512 Q515 Q516 Q517 Q51811 Q51821 Q51828 Q520 Q5210 Q522 Q523 Q524 Q525 Q526 Q5270 Q5271 Q5279 Q528 Q529 Q5300 Q5301 Q5302 Q5310 Q53111 Q53112 Q5312 Q5313 Q5320 Congenital absence of ovary, bilateral Developmental ovarian cyst Congenital torsion of ovary Accessory ovary Ovarian streak Other congenital malformation of ovary Embryonic cyst of fallopian tube Embryonic cyst of broad ligament Other congenital malformations of fallopian tube and broad ligament Agenesis and aplasia of uterus Doubling of uterus with doubling of cervix and vagina without obstruction Doubling of uterus with doubling of cervix and vagina with obstruction Other doubling of uterus Agenesis and aplasia of cervix Embryonic cyst of cervix Congenital fistulae between uterus and digestive and urinary tracts Hypoplasia of uterus Hypoplasia of cervix Other congenital malformations of cervix Congenital absence of vagina Doubling of vagina, unspecified Congenital rectovaginal fistula Imperforate hymen Other congenital malformations of vagina Fusion of labia Congenital malformation of clitoris Unspecified congenital malformations of vulva Congenital absence of vulva Other congenital malformations of vulva Other specified congenital malformations of female genitalia Congenital malformation of female genitalia, unspecified Ectopic testis, unspecified Ectopic testis, unilateral Ectopic testes, bilateral Unspecified undescended testicle, unilateral Unilateral intraabdominal testis Unilateral inguinal testis Ectopic perineal testis, unilateral Unilateral high scrotal testis Undescended testicle, unspecified, bilateral CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 22

23 Q53211 Q53212 Q5322 Q5323 Q539 Q540 Q541 Q542 Q543 Q544 Q548 Q550 Q551 Q5521 Q5522 Q5523 Q5529 Q553 Q554 Q555 Q5561 Q5562 Q5563 Q5564 Q5569 Q558 Q559 Q560 Q561 Q562 Q563 Q564 Q600 Q601 Q603 Q604 Q606 Q6101 Q6119 Bilateral intraabdominal testes Bilateral inguinal testes Ectopic perineal testis, bilateral Bilateral high scrotal testes Undescended testicle, unspecified Hypospadias, balanic Hypospadias, penile Hypospadias, penoscrotal Hypospadias, perineal Congenital chordee Other hypospadias Absence and aplasia of testis Hypoplasia of testis and scrotum Polyorchism Retractile testis Scrotal transposition Other congenital malformations of testis and scrotum Atresia of vas deferens Other congenital malformations of vas deferens, epididymis, seminal vesicles and prostate Congenital absence and aplasia of penis Curvature of penis (lateral) Hypoplasia of penis Congenital torsion of penis Hidden penis Other congenital malformation of penis Other specified congenital malformations of male genital organs Congenital malformation of male genital organ, unspecified Hermaphroditism, not elsewhere classified Male pseudohermaphroditism, not elsewhere classified Female pseudohermaphroditism, not elsewhere classified Pseudohermaphroditism, unspecified Indeterminate sex, unspecified Renal agenesis, unilateral Renal agenesis, bilateral Renal hypoplasia, unilateral Renal hypoplasia, bilateral Potter's syndrome Congenital single renal cyst Other polycystic kidney, infantile type CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 23

24 Q612 Q613 Q614 Q615 Q618 Q619 Q6211 Q6212 Q622 Q6231 Q6239 Q624 Q625 Q6261 Q6262 Q6263 Q628 Q630 Q631 Q632 Q633 Q638 Q640 Q6410 Q6411 Q6412 Q6419 Q642 Q6431 Q6432 Q6433 Q6439 Q644 Q645 Q646 Q6471 Q6472 Q6473 Q6474 Q6475 Polycystic kidney, adult type Polycystic kidney, unspecified Renal dysplasia Medullary cystic kidney Other cystic kidney diseases Cystic kidney disease, unspecified Congenital occlusion of ureteropelvic junction Congenital occlusion of ureterovesical orifice Congenital megaureter Congenital ureterocele, orthotopic Other obstructive defects of renal pelvis and ureter Agenesis of ureter Duplication of ureter Deviation of ureter Displacement of ureter Anomalous implantation of ureter Other congenital malformations of ureter Accessory kidney Lobulated, fused and horseshoe kidney Ectopic kidney Hyperplastic and giant kidney Other specified congenital malformations of kidney Epispadias Exstrophy of urinary bladder, unspecified Supravesical fissure of urinary bladder Cloacal exstrophy of urinary bladder Other exstrophy of urinary bladder Congenital posterior urethral valves Congenital bladder neck obstruction Congenital stricture of urethra Congenital stricture of urinary meatus Other atresia and stenosis of urethra and bladder neck Malformation of urachus Congenital absence of bladder and urethra Congenital diverticulum of bladder Congenital prolapse of urethra Congenital prolapse of urinary meatus Congenital urethrorectal fistula Double urethra Double urinary meatus CPT ONLY - COPYRIGHT 2016 AMERICAN MEDICAL ASSOCIATION. ALL RIGHTS RESERVED. 24