MEDICARE LOCAL COVERAGE DETERMINATION COMMONLY USED DIAGNOSIS CODES
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1 MEDICARE LOCAL COVERAGE DETERMINATION COMMONLY USED DIAGNOSIS CODES Urine drug testing (UDT) provides objective information to assist clinicians in identifying the presence or absence of drugs or drug classes in the body and making treatment decisions. The LCD provides an overview of presumptive and definitive UDT by various methodologies and designates documentation by the clinician in the patient s medical record, the medical necessity for, and testing ordered on an individual basis. ICD-10-CM codes that support medical necessity are listed, but it is not enough to link the procedure code to a correct payable ICD-10-CM code. The diagnosis must be present for the procedure to be paid, and the procedure must be reasonable and medically necessary for the diagnosis. The list was compiled from the Medicare Local Coverage Determination Policy and is provided by Dominion Diagnostics as a customer service tool only and Dominon Diagnostics makes no recommendation regarding the use of any particular diagnosis codes. All diagnosis information should be reflected in the patient s medical record. An ICD-10-CM book should be used as a complete reference. E87.2 Acidosis F10.20 Alcohol dependence, uncomplicated F11.20 Opioid dependence, uncomplicated F Opioid dependence with intoxica on, uncomplicated F Opioid dependence with intoxica on delirium F Opioid dependence with intoxica on with perceptual disturbance F Opioid dependence with intoxica on, unspecified F11.23 Opioid dependence with withdrawal F11.24 F F F F F F Opioid dependence with opioid-induced mood Opioid dependence with opioid-induced psycho c with delusions Opioid dependence with opioid-induced psycho c with hallucina ons Opioid dependence with opioid-induced psycho c, unspecified Opioid dependence with opioid-induced sexual dysfunc on Opioid dependence with opioid-induced sleep Opioid dependence with other opioid-induced F11.29 Opioid dependence with unspecified opioid-induced F18.10 Inhalant abuse, uncomplicated F Inhalant abuse with intoxica on, uncomplicated F18.90 Inhalant use, unspecified, uncomplicated F19.20 Other psychoac ve substance dependence, uncomplicated F20.0 Paranoid schizophrenia F20.1 Disorganized schizophrenia F20.2 Catatonic schizophrenia F20.89 Other schizophrenia F55.0 Abuse of antacids F55.1 Abuse of herbal or folk remedies F55.2 Abuse of laxa ves F55.3 Abuse of steroids or hormones F55.4 Abuse of vitamins F55.8 Abuse of other non-psychoac ve substances G G G G G G G G G G G syndromes, not intractable, with status syndromes, not intractable, without status syndromes, intractable, with status syndromes, intractable, without status not intractable, with status not intractable, without status intractable, with status intractable, without status Epilepsy, unspecified, not intractable, with status Epilepsy, unspecified, not intractable, without status Epilepsy, unspecified, intractable, with status G Epilepsy, unspecified, intractable, without status G89.29 Other chronic pain G89.4 Chronic pain syndrome I44.0 Atrioventricular block, first degree I44.1 Atrioventricular block, second degree I44.30 Unspecified atrioventricular block I45.81 Long QT syndrome I47.0 Re-entry ventricular arrhythmia I47.1 Supraventricular tachycardia I47.2 Ventricular tachycardia I49.2 Junc onal premature depolariza on M25.50 Pain in unspecified joint M47.21 Other spondylosis with radiculopathy, occipitoatlanto-axial M47.22 Other spondylosis with radiculopathy, cervical M47.23 Other spondylosis with radiculopathy, cervicothoracic M47.26 Other spondylosis with radiculopathy, lumbar
2 M47.27 M47.28 M M M M M Other spondylosis with radiculopathy, lumbosacral Other spondylosis with radiculopathy, sacral and sacrococcygeal occipito-atlanto-axial cervical cervicothoracic lumbar lumbosacral M sacral and sacrococcygeal M Other spondylosis, occipito-atlanto-axial M Other spondylosis, cervical M Other spondylosis, cervicothoracic M Other spondylosis, lumbar M Other spondylosis, lumbosacral M Other spondylosis, sacral and sacrococcygeal M51.14 M51.15 M51.16 thoracic thoracolumbar lumbar M51.17 lumbosacral M51.36 Other intervertebral disc degenera on, lumbar M51.37 Other intervertebral disc degenera on, lumbosacral M54.14 Radiculopathy, thoracic M54.15 Radiculopathy, thoracolumbar M54.16 Radiculopathy, lumbar M54.17 Radiculopathy, lumbosacral M54.18 Radiculopathy, sacral and sacrococcygeal M54.2 Cervicalgia M54.5 Low back pain M Other myosi s, right shoulder M Other myosi s, le shoulder M Other myosi s, right upper arm M Other myosi s, le upper arm M Other myosi s, right forearm M Other myosi s, le forearm M Other myosi s, right hand M Other myosi s, le hand M Other myosi s, right thigh M Other myosi s, le thigh M Other myosi s, right lower leg M Other myosi s, le lower leg M Other myosi s, right ankle and foot M Other myosi s, le ankle and foot M60.88 Other myosi s, other site M60.89 Other myosi s, mul ple sites M60.9 Myosi s, unspecified M79.1 Myalgia M79.2 Neuralgia and neuri s, unspecified M79.7 Fibromyalgia R40.0 Somnolence R40.1 Stupor R40.20 Unspecified coma R Coma scale, eyes open, never, unspecified me R Coma scale, eyes open, never, in the field [EMT or ambulance] R Coma scale, eyes open, never, at arrival to emergency department R Coma scale, eyes open, never, at hospital admission R Coma scale, eyes open, never, 24 hours or more a er hospital admission R Coma scale, eyes open, to pain, unspecified me R Coma scale, eyes open, to pain, in the field [EMT or ambulance] R Coma scale, eyes open, to pain, at arrival to emergency department R Coma scale, eyes open, to pain, at hospital admission R R R R R R R R R R R Coma scale, eyes open, to pain, 24 hours or more a er hospital admission Coma scale, best verbal response, none, unspecified me Coma scale, best verbal response, none, in the field [EMT or ambulance] Coma scale, best verbal response, none, at arrival to emergency department Coma scale, best verbal response, none, at hospital admission Coma scale, best verbal response, none, 24 hours or more a er hospital admission words, unspecified me words, in the field [EMT or ambulance] words, at arrival to emergency department words, at hospital admission words, 24 hours or more a er hospital admission
3 R R R R R R R R R R R R R R Coma scale, best motor response, none, unspecified me Coma scale, best motor response, none, in the field [EMT or ambulance] Coma scale, best motor response, none, at arrival to emergency department Coma scale, best motor response, none, at hospital admission Coma scale, best motor response, none, 24 hours or more a er hospital admission Coma scale, best motor response, extension, unspecified me Coma scale, best motor response, extension, in the field [EMT or ambulance] Coma scale, best motor response, extension, at arrival to emergency department Coma scale, best motor response, extension, at hospital admission Coma scale, best motor response, extension, 24 hours or more a er hospital admission unspecified me in the field [EMT or ambulance] at arrival to emergency department at hospital admission R hours or more a er hospital admission R44.0 Auditory hallucina ons R44.2 Other hallucina ons R44.3 Hallucina ons, unspecified R56.9 Unspecified convulsions T39.011A T39.012A T39.013A T39.014A T39.091A T39.092A T39.093A T39.094A T39.1X1A T39.1X2A Poisoning by aspirin, accidental (uninten onal), ini al Poisoning by aspirin, inten onal self-harm, ini al Poisoning by aspirin, assault, ini al Poisoning by aspirin, undetermined, ini al Poisoning by salicylates, accidental (uninten onal), ini al Poisoning by salicylates, inten onal self-harm, ini al Poisoning by salicylates, assault, ini al Poisoning by salicylates, undetermined, ini al Poisoning by 4-Aminophenol deriva ves, accidental (uninten onal), ini al Poisoning by 4-Aminophenol deriva ves, inten onal self-harm, ini al T39.1X3A T39.1X4A T39.2X1A T39.2X2A T39.2X3A T39.2X4A T39.311A T39.312A T39.313A T39.314A T39.391A T39.392A T39.393A T39.394A T40.0X1A T40.0X2A T40.0X3A T40.0X4A T40.1X1A T40.1X2A T40.1X3A T40.1X4A T40.2X1A T40.2X2A T40.2X3A T40.2X4A T40.3X1A T40.3X2A Poisoning by 4-Aminophenol deriva ves, assault, ini al Poisoning by 4-Aminophenol deriva ves, undetermined, ini al Poisoning by pyrazolone deriva ves, accidental (uninten onal), ini al Poisoning by pyrazolone deriva ves, inten onal selfharm, ini al Poisoning by pyrazolone deriva ves, assault, ini al Poisoning by pyrazolone deriva ves, undetermined, ini al Poisoning by propionic acid deriva ves, accidental (uninten onal), ini al Poisoning by propionic acid deriva ves, inten onal self-harm, ini al Poisoning by propionic acid deriva ves, assault, ini al Poisoning by propionic acid deriva ves, undetermined, ini al drugs [NSAID], accidental (uninten onal), ini al drugs [NSAID], inten onal self-harm, ini al drugs [NSAID], assault, ini al drugs [NSAID], undetermined, ini al Poisoning by opium, accidental (uninten onal), ini al Poisoning by opium, inten onal self-harm, ini al Poisoning by opium, assault, ini al Poisoning by opium, undetermined, ini al Poisoning by heroin, accidental (uninten onal), ini al Poisoning by heroin, inten onal self-harm, ini al Poisoning by heroin, assault, ini al Poisoning by heroin, undetermined, ini al Poisoning by other opioids, accidental (uninten onal), ini al Poisoning by other opioids, inten onal self-harm, ini al Poisoning by other opioids, assault, ini al Poisoning by other opioids, undetermined, ini al Poisoning by methadone, accidental (uninten onal), ini al Poisoning by methadone, inten onal self-harm, ini al
4 T40.3X3A T40.3X4A T40.4X1A T40.4X2A T40.4X3A T40.4X4A T40.601A T40.602A T40.603A T40.604A T40.691A T40.692A T40.693A T40.694A T40.7X1A T40.7X2A T40.7X3A T40.7X4A T40.8X1A T40.8X2A T40.8X3A T40.8X4A T40.901A T40.902A T40.903A T40.904A Poisoning by methadone, assault, ini al Poisoning by methadone, undetermined, ini al Poisoning by other synthe c narco cs, accidental (uninten onal), ini al Poisoning by other synthe c narco cs, inten onal self-harm, ini al Poisoning by other synthe c narco cs, assault, ini al Poisoning by other synthe c narco cs, undetermined, ini al Poisoning by unspecified narco cs, accidental (uninten onal), ini al Poisoning by unspecified narco cs, inten onal selfharm, ini al Poisoning by unspecified narco cs, assault, ini al Poisoning by unspecified narco cs, undetermined, ini al Poisoning by other narco cs, accidental (uninten onal), ini al Poisoning by other narco cs, inten onal self-harm, ini al Poisoning by other narco cs, assault, ini al Poisoning by other narco cs, undetermined, ini al Poisoning by cannabis (deriva ves), accidental (uninten onal), ini al Poisoning by cannabis (deriva ves), inten onal selfharm, ini al Poisoning by cannabis (deriva ves), assault, ini al Poisoning by cannabis (deriva ves), undetermined, ini al Poisoning by lysergide [LSD], accidental (uninten onal), ini al Poisoning by lysergide [LSD], inten onal self-harm, ini al Poisoning by lysergide [LSD], assault, ini al Poisoning by lysergide [LSD], undetermined, ini al [hallucinogens], accidental (uninten onal), ini al [hallucinogens], inten onal self-harm, ini al [hallucinogens], assault, ini al [hallucinogens], undetermined, ini al T40.991A T40.992A T40.993A T40.994A T42.0X1A T42.0X2A T42.0X3A T42.0X4A T42.3X1A T42.3X2A T42.3X3A T42.3X4A T42.4X1A T42.4X2A T42.4X3A T42.4X4A T42.6X1A T42.6X2A T42.6X3A T42.6X4A T42.71XA T42.72XA T42.73XA T42.74XA T43.011A accidental (uninten onal), ini al inten onal self-harm, ini al assault, ini al undetermined, ini al Poisoning by hydantoin deriva ves, accidental (uninten onal), ini al Poisoning by hydantoin deriva ves, inten onal selfharm, ini al Poisoning by hydantoin deriva ves, assault, ini al Poisoning by hydantoin deriva ves, undetermined, ini al Poisoning by barbiturates, accidental (uninten onal), ini al Poisoning by barbiturates, inten onal self-harm, ini al Poisoning by barbiturates, assault, ini al Poisoning by barbiturates, undetermined, ini al Poisoning by benzodiazepines, accidental (uninten onal), ini al Poisoning by benzodiazepines, inten onal self-harm, ini al Poisoning by benzodiazepines, assault, ini al Poisoning by benzodiazepines, undetermined, ini al drugs, accidental (uninten onal), ini al drugs, inten onal self-harm, ini al drugs, assault, ini al drugs, undetermined, ini al drugs, accidental (uninten onal), ini al drugs, inten onal self-harm, ini al drugs, assault, ini al drugs, undetermined, ini al Poisoning by tricyclic an depressants, accidental (uninten onal), ini al
5 T43.012A T43.013A T43.014A T43.021A T43.022A T43.023A T43.024A T43.1X1A T43.1X2A T43.1X3A T43.1X4A T43.201A T43.202A T43.203A T43.204A T43.211A T43.212A T43.213A T43.214A T43.221A T43.222A T43.223A T43.224A T43.291A Poisoning by tricyclic an depressants, inten onal self-harm, ini al Poisoning by tricyclic an depressants, assault, ini al Poisoning by tricyclic an depressants, undetermined, ini al Poisoning by tetracyclic an depressants, accidental (uninten onal), ini al Poisoning by tetracyclic an depressants, inten onal self-harm, ini al Poisoning by tetracyclic an depressants, assault, ini al Poisoning by tetracyclic an depressants, undetermined, ini al an depressants, accidental (uninten onal), ini al an depressants, inten onal self-harm, ini al an depressants, assault, ini al an depressants, undetermined, ini al Poisoning by unspecified an depressants, accidental (uninten onal), ini al Poisoning by unspecified an depressants, inten onal self-harm, ini al Poisoning by unspecified an depressants, assault, ini al Poisoning by unspecified an depressants, undetermined, ini al reuptake inhibitors, accidental (uninten onal), ini al reuptake inhibitors, inten onal self-harm, ini al reuptake inhibitors, assault, ini al reuptake inhibitors, undetermined, ini al accidental (uninten onal), ini al inten onal self-harm, ini al assault, ini al undetermined, ini al Poisoning by other an depressants, accidental (uninten onal), ini al T43.292A T43.293A T43.294A T43.3X1A T43.3X2A T43.3X3A T43.3X4A T43.4X1A T43.4X2A T43.4X3A T43.4X4A T43.501A T43.502A T43.503A T43.504A T43.591A T43.592A T43.593A T43.594A T43.601A T43.602A T43.603A T43.604A T43.611A T43.612A Poisoning by other an depressants, inten onal selfharm, ini al Poisoning by other an depressants, assault, ini al Poisoning by other an depressants, undetermined, ini al neurolep cs, accidental (uninten onal), ini al neurolep cs, inten onal self-harm, ini al neurolep cs, assault, ini al neurolep cs, undetermined, ini al neurolep cs, accidental (uninten onal), ini al neurolep cs, inten onal self-harm, ini al neurolep cs, assault, ini al neurolep cs, undetermined, ini al neurolep cs, accidental (uninten onal), ini al neurolep cs, inten onal self-harm, ini al neurolep cs, assault, ini al neurolep cs, undetermined, ini al accidental (uninten onal), ini al inten onal self-harm, ini al assault, ini al undetermined, ini al Poisoning by unspecified psychos mulants, accidental (uninten onal), ini al Poisoning by unspecified psychos mulants, inten onal self-harm, ini al Poisoning by unspecified psychos mulants, assault, ini al Poisoning by unspecified psychos mulants, undetermined, ini al Poisoning by caffeine, accidental (uninten onal), ini al Poisoning by caffeine, inten onal self-harm, ini al
6 T43.613A T43.614A T43.621A T43.622A T43.623A T43.624A T43.631A T43.632A T43.633A T43.634A T43.691A T43.692A T43.693A T43.694A T43.8X1A T43.8X2A T43.8X3A T43.8X4A T43.91XA T43.92XA T43.93XA T43.94XA T45.0X1A T45.0X2A T45.0X3A T45.0X4A T46.0X1A Poisoning by caffeine, assault, ini al Poisoning by caffeine, undetermined, ini al Poisoning by amphetamines, accidental (uninten onal), ini al Poisoning by amphetamines, inten onal self-harm, ini al Poisoning by amphetamines, assault, ini al Poisoning by amphetamines, undetermined, ini al Poisoning by methylphenidate, accidental (uninten onal), ini al Poisoning by methylphenidate, inten onal self-harm, ini al Poisoning by methylphenidate, assault, ini al Poisoning by methylphenidate, undetermined, ini al Poisoning by other psychos mulants, accidental (uninten onal), ini al Poisoning by other psychos mulants, inten onal selfharm, ini al Poisoning by other psychos mulants, assault, ini al Poisoning by other psychos mulants, undetermined, ini al Poisoning by other psychotropic drugs, accidental (uninten onal), ini al Poisoning by other psychotropic drugs, inten onal self-harm, ini al Poisoning by other psychotropic drugs, assault, ini al Poisoning by other psychotropic drugs, undetermined, ini al Poisoning by unspecified psychotropic drug, accidental (uninten onal), ini al Poisoning by unspecified psychotropic drug, inten onal self-harm, ini al Poisoning by unspecified psychotropic drug, assault, ini al Poisoning by unspecified psychotropic drug, undetermined, ini al accidental (uninten onal), ini al inten onal self-harm, ini al assault, ini al undetermined, ini al Poisoning by cardiac-s mulant glycosides and drugs of similar ac on, accidental (uninten onal), ini al T46.0X2A T46.0X3A T46.0X4A T50.901A T50.902A T50.903A Poisoning by cardiac-s mulant glycosides and drugs of similar ac on, inten onal self-harm, ini al Poisoning by cardiac-s mulant glycosides and drugs of similar ac on, assault, ini al Poisoning by cardiac-s mulant glycosides and drugs of similar ac on, undetermined, ini al Poisoning by unspecified drugs, medicaments and biological substances, accidental (uninten onal), ini al Poisoning by unspecified drugs, medicaments and biological substances, inten onal self-harm, ini al Poisoning by unspecified drugs, medicaments and biological substances, assault, ini al Poisoning by unspecified drugs, medicaments T50.904A and biological substances, undetermined, ini al Z51.81 Encounter for therapeu c drug level monitoring Z79.3 Long term (current) use of hormonal contracep ves Z Long term (current) use of opiate analgesic Z Other long term (current) drug therapy Z91.19 Pa ent's noncompliance with other medical treatment and regimen
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