CMS Limitations Guide MRA Radiology Services Starting July 1, 2008, CMS has placed numerous medical necessity limits on tests and procedures. This reference guide provides you with all of the latest changes. This guide is not an all-inclusive list of National Coverage Documents (NCD) and Local Coverage Documents (LCD). Please consult the CMS website for additional information at cms.hhs.gov/mcd/search.asp?clickon=search. You can search by LCD or NCD or keyword and region. CMS will deny payment if the correct diagnosis codes are not entered on the order form, and your patient s test or procedure will not be covered. We compiled this information in one location to make it easier for you to find the proper codes for medically necessary diagnoses. It is the responsibility of the provider to code to the highest level specified in the ICD-9-CM (e.g. to the fourth or fifth digit). The correct use of an ICD-9-CM code listed below does not assure coverage of a service. The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination. We will continue to update this list as new CMS limitations are announced. You can always find the most current list on mymunson.org. If you have any questions, please contact Kari Smith, Office Coordinator, at (231) 935-2296, or Karen Fouch, Manager, Patient Access Services, at (231) 935-6164. MRA of Abdomen and Pelvis (L25367)...2 MRA of Chest (L25367)...5 MRA of Head or Neck (L25367)...6 MRA of the Lower Extremities...13 Non-covered services ICD-9-CM codes do not support the medical necessity for CPT codes listed below as they are always non-covered. 72159 MAGNETIC RESONANCE ANGIOGRAPHY, SPINAL CANAL AND CONTENTS, WITH OR WITHOUT CONTRAST MATERIAL(S) 73225 MAGNETIC RESONANCE ANGIOGRAPHY, UPPER EXTREMITY, WITH OR WITHOUT CONTRAST MATERIAL(S) - 1 -
MRA of Abdomen and Pelvis (L25367) 223.0 BENIGN NEOPLASM OF KIDNEY EXCEPT PELVIS 401.0 MALIGNANT ESSENTIAL HYPERTENSION 401.1 BENIGN ESSENTIAL HYPERTENSION 403.00 HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 403.01 HYPERTENSIVE CHRONIC KIDNEY DISEASE, MALIGNANT, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 403.10 HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 403.11 HYPERTENSIVE CHRONIC KIDNEY DISEASE, BENIGN, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 403.90 HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 403.91 HYPERTENSIVE CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 404.00 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 404.01 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 404.02 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 404.03 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, MALIGNANT, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 404.10 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 404.11 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 404.12 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 404.13 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, BENIGN, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 404.90 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 404.91 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE I THROUGH STAGE IV, OR UNSPECIFIED 404.92 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITHOUT HEART FAILURE AND WITH CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 404.93 HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE, UNSPECIFIED, WITH HEART FAILURE AND CHRONIC KIDNEY DISEASE STAGE V OR END STAGE RENAL DISEASE 405.01 MALIGNANT RENOVASCULAR HYPERTENSION 405.11 BENIGN RENOVASCULAR HYPERTENSION - 2 -
405.91 UNSPECIFIED RENOVASCULAR HYPERTENSION 440.0 ATHEROSCLEROSIS OF AORTA 440.1 ATHEROSCLEROSIS OF RENAL ARTERY 440.20 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED 440.21 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION 440.22 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN 440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION 440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE 441.02 DISSECTION OF AORTA ABDOMINAL 441.03 DISSECTION OF AORTA THORACOABDOMINAL 441.4 ABDOMINAL ANEURYSM WITHOUT RUPTURE 441.7 THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE 441.9 AORTIC ANEURYSM OF UNSPECIFIED SITE WITHOUT RUPTURE 442.1 ANEURYSM OF RENAL ARTERY 442.2 ANEURYSM OF ILIAC ARTERY 442.3 ANEURYSM OF ARTERY OF LOWER EXTREMITY 442.83 ANEURYSM OF SPLENIC ARTERY 442.84 ANEURYSM OF OTHER VISCERAL ARTERY 442.89 ANEURYSM OF OTHER SPECIFIED SITE 443.22 DISSECTION OF ILIAC ARTERY 443.23 DISSECTION OF RENAL ARTERY 443.9 PERIPHERAL VASCULAR DISEASE UNSPECIFIED 444.0 EMBOLISM AND THROMBOSIS OF ABDOMINAL AORTA 444.1 EMBOLISM AND THROMBOSIS OF THORACIC AORTA 444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY 445.81 ATHEROEMBOLISM OF KIDNEY 447.0 ARTERIOVENOUS FISTULA ACQUIRED 447.1 STRICTURE OF ARTERY 447.3 HYPERPLASIA OF RENAL ARTERY 447.5 NECROSIS OF ARTERY 447.8 OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES 557.0 ACUTE VASCULAR INSUFFICIENCY OF INTESTINE 557.1 CHRONIC VASCULAR INSUFFICIENCY OF INTESTINE 584.5 ACUTE KIDNEY FAILURE WITH LESION OF TUBULAR NECROSIS 584.6 ACUTE KIDNEY FAILURE WITH LESION OF RENAL CORTICAL NECROSIS - 3 -
584.7 ACUTE KIDNEY FAILURE WITH LESION OF RENAL MEDULLARY [PAPILLARY] NECROSIS 584.8 ACUTE KIDNEY FAILURE WITH OTHER SPECIFIED PATHOLOGICAL LESION IN KIDNEY 584.9 ACUTE KIDNEY FAILURE, UNSPECIFIED 585.1 CHRONIC KIDNEY DISEASE, STAGE I 585.2 CHRONIC KIDNEY DISEASE, STAGE II (MILD) 585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) 585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) 585.5 CHRONIC KIDNEY DISEASE, STAGE V 585.6 END STAGE RENAL DISEASE 585.9 CHRONIC KIDNEY DISEASE, UNSPECIFIED 587 RENAL SCLEROSIS UNSPECIFIED 589.0 UNILATERAL SMALL KIDNEY 589.1 BILATERAL SMALL KIDNEYS 589.9 SMALL KIDNEY UNSPECIFIED 593.81 VASCULAR DISORDERS OF KIDNEY 747.62 RENAL VESSEL ANOMALY 747.64 LOWER LIMB VESSEL ANOMALY 793.6* NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF ABDOMINAL AREA, INCLUDING RETROPERITONEUM 902.0 INJURY TO ABDOMINAL AORTA 902.40 INJURY TO RENAL VESSEL(S) UNSPECIFIED 902.41 INJURY TO RENAL ARTERY 902.50 INJURY TO ILIAC VESSEL(S) UNSPECIFIED 902.51 INJURY TO HYPOGASTRIC ARTERY 902.53 INJURY TO ILIAC ARTERY 996.1 MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT 996.62 INFECTION AND INFLAMMATORY REACTION DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT 996.74 OTHER COMPLICATIONS DUE TO OTHER VASCULAR DEVICE IMPLANT AND GRAFT 996.81 COMPLICATIONS OF TRANSPLANTED KIDNEY V42.0 KIDNEY REPLACED BY TRANSPLANT V58.73 AFTERCARE FOLLOWING SURGERY OF THE CIRCULATORY SYSTEM NOT ELSEWHERE CLASSIFIED V59.4 KIDNEY DONORS V70.8 OTHER SPECIFIED GENERAL MEDICAL EXAMINATIONS - 4 -
MRA of Chest (L25367) 093.0 ANEURYSM OF AORTA SPECIFIED AS SYPHILITIC 415.0 ACUTE COR PULMONALE 415.11 IATROGENIC PULMONARY EMBOLISM AND INFARCTION 415.12 SEPTIC PULMONARY EMBOLISM 415.19 OTHER PULMONARY EMBOLISM AND INFARCTION 441.01 DISSECTION OF AORTA THORACIC 441.03 DISSECTION OF AORTA THORACOABDOMINAL 441.2 THORACIC ANEURYSM WITHOUT RUPTURE 441.7 THORACOABDOMINAL ANEURYSM WITHOUT RUPTURE 444.1 EMBOLISM AND THROMBOSIS OF THORACIC AORTA 584.9 ACUTE KIDNEY FAILURE, UNSPECIFIED 585.3 CHRONIC KIDNEY DISEASE, STAGE III (MODERATE) 585.4 CHRONIC KIDNEY DISEASE, STAGE IV (SEVERE) 585.5 CHRONIC KIDNEY DISEASE, STAGE V 585.6 END STAGE RENAL DISEASE 586 RENAL FAILURE UNSPECIFIED 747.10 COARCTATION OF AORTA (PREDUCTAL) (POSTDUCTAL) 747.11 INTERRUPTION OF AORTIC ARCH 759.82 MARFAN SYNDROME 793.2* NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF OTHER INTRATHORACIC ORGANS 794.2 NONSPECIFIC ABNORMAL RESULTS OF FUNCTION STUDY OF PULMONARY SYSTEM V12.59 PERSONAL HISTORY OF OTHER DISEASES OF CIRCULATORY SYSTEM NOT ELSEWHERE CLASSIFIED V14.8 PERSONAL HISTORY OF ALLERGY TO OTHER SPECIFIED MEDICINAL AGENTS V15.08 PERSONAL HISTORY OF ALLERGY TO RADIOGRAPHIC DYE V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY - 5 -
MRA of Head or Neck (L25367) 190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID 190.1 MALIGNANT NEOPLASM OF ORBIT 190.2 MALIGNANT NEOPLASM OF LACRIMAL GLAND 190.3 MALIGNANT NEOPLASM OF CONJUNCTIVA 190.4 MALIGNANT NEOPLASM OF CORNEA 190.5 MALIGNANT NEOPLASM OF RETINA 190.6 MALIGNANT NEOPLASM OF CHOROID 190.7 MALIGNANT NEOPLASM OF LACRIMAL DUCT 190.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE 191.0 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES 191.1 MALIGNANT NEOPLASM OF FRONTAL LOBE 191.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE 191.3 MALIGNANT NEOPLASM OF PARIETAL LOBE 191.4 MALIGNANT NEOPLASM OF OCCIPITAL LOBE 191.5 MALIGNANT NEOPLASM OF VENTRICLES 191.6 MALIGNANT NEOPLASM OF CEREBELLUM NOS 191.7 MALIGNANT NEOPLASM OF BRAIN STEM 191.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN 191.9 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE 192.1 MALIGNANT NEOPLASM OF CEREBRAL MENINGES 194.3 MALIGNANT NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT 194.4 MALIGNANT NEOPLASM OF PINEAL GLAND 194.5 MALIGNANT NEOPLASM OF CAROTID BODY 194.6 MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA 198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD 198.4 SECONDARY MALIGNANT NEOPLASM OF OTHER PARTS OF NERVOUS SYSTEM 225.0 BENIGN NEOPLASM OF BRAIN 225.1 BENIGN NEOPLASM OF CRANIAL NERVES 225.2 BENIGN NEOPLASM OF CEREBRAL MENINGES 227.3 BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT 227.4 BENIGN NEOPLASM OF PINEAL GLAND 227.5 BENIGN NEOPLASM OF CAROTID BODY 227.6 BENIGN NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA - 6 -
228.02 HEMANGIOMA OF INTRACRANIAL STRUCTURES 228.03 HEMANGIOMA OF RETINA 237.5 NEOPLASM OF UNCERTAIN BEHAVIOR OF BRAIN AND SPINAL CORD 237.6 NEOPLASM OF UNCERTAIN BEHAVIOR OF MENINGES 237.70 NEUROFIBROMATOSIS UNSPECIFIED 237.71 NEUROFIBROMATOSIS TYPE 1 VON RECKLINGHAUSEN'S DISEASE 237.72 NEUROFIBROMATOSIS TYPE 2 ACOUSTIC NEUROFIBROMATOSIS 239.6 NEOPLASM OF UNSPECIFIED NATURE OF BRAIN 282.60 SICKLE-CELL DISEASE UNSPECIFIED 325 PHLEBITIS AND THROMBOPHLEBITIS OF INTRACRANIAL VENOUS SINUSES 350.1 TRIGEMINAL NEURALGIA 350.2 ATYPICAL FACE PAIN 350.8 OTHER SPECIFIED TRIGEMINAL NERVE DISORDERS 362.30 RETINAL VASCULAR OCCLUSION UNSPECIFIED 362.31 CENTRAL RETINAL ARTERY OCCLUSION 362.32 RETINAL ARTERIAL BRANCH OCCLUSION 362.33 PARTIAL RETINAL ARTERIAL OCCLUSION 362.34 TRANSIENT RETINAL ARTERIAL OCCLUSION 368.12 TRANSIENT VISUAL LOSS 368.40 VISUAL FIELD DEFECT UNSPECIFIED 368.46 HOMONYMOUS BILATERAL FIELD DEFECTS 368.47 HETERONYMOUS BILATERAL FIELD DEFECTS 377.01 PAPILLEDEMA ASSOCIATED WITH INCREASED INTRACRANIAL PRESSURE 377.04 FOSTER-KENNEDY SYNDROME 377.42 HEMORRHAGE IN OPTIC NERVE SHEATHS 377.51 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH PITUITARY NEOPLASMS AND DISORDERS 377.52 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH OTHER NEOPLASMS 377.53 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH VASCULAR DISORDERS 377.54 DISORDERS OF OPTIC CHIASM ASSOCIATED WITH INFLAMMATORY DISORDERS 377.61 DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH NEOPLASMS 377.62 DISORDERS OF OTHER VISUAL PATHWAYS ASSOCIATED WITH VASCULAR DISORDERS 377.71 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH NEOPLASMS 377.72 DISORDERS OF VISUAL CORTEX ASSOCIATED WITH VASCULAR DISORDERS 378.51 THIRD OR OCULOMOTOR NERVE PALSY PARTIAL 378.52 THIRD OR OCULOMOTOR NERVE PALSY TOTAL - 7 -
378.53 FOURTH OR TROCHLEAR NERVE PALSY 378.54 SIXTH OR ABDUCENS NERVE PALSY 430 SUBARACHNOID HEMORRHAGE 431 INTRACEREBRAL HEMORRHAGE 432.0 NONTRAUMATIC EXTRADURAL HEMORRHAGE 432.1 SUBDURAL HEMORRHAGE 432.9 UNSPECIFIED INTRACRANIAL HEMORRHAGE 433.00 OCCLUSION AND STENOSIS OF BASILAR ARTERY WITHOUT CEREBRAL INFARCTION 433.01 OCCLUSION AND STENOSIS OF BASILAR ARTERY WITH CEREBRAL INFARCTION 433.10 OCCLUSION AND STENOSIS OF CAROTID ARTERY WITHOUT CEREBRAL INFARCTION 433.11 OCCLUSION AND STENOSIS OF CAROTID ARTERY WITH CEREBRAL INFARCTION 433.20 OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITHOUT CEREBRAL INFARCTION 433.21 OCCLUSION AND STENOSIS OF VERTEBRAL ARTERY WITH CEREBRAL INFARCTION 433.30 OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITHOUT CEREBRAL INFARCTION 433.31 OCCLUSION AND STENOSIS OF MULTIPLE AND BILATERAL PRECEREBRAL ARTERIES WITH CEREBRAL INFARCTION 433.80 OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY WITHOUT CEREBRAL INFARCTION 433.81 OCCLUSION AND STENOSIS OF OTHER SPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION 433.90 OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITHOUT CEREBRAL INFARCTION 433.91 OCCLUSION AND STENOSIS OF UNSPECIFIED PRECEREBRAL ARTERY WITH CEREBRAL INFARCTION 434.00 CEREBRAL THROMBOSIS WITHOUT CEREBRAL INFARCTION 434.01 CEREBRAL THROMBOSIS WITH CEREBRAL INFARCTION 434.10 CEREBRAL EMBOLISM WITHOUT CEREBRAL INFARCTION 434.11 CEREBRAL EMBOLISM WITH CEREBRAL INFARCTION 434.90 CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITHOUT CEREBRAL INFARCTION 434.91 CEREBRAL ARTERY OCCLUSION UNSPECIFIED WITH CEREBRAL INFARCTION 435.0 BASILAR ARTERY SYNDROME 435.1 VERTEBRAL ARTERY SYNDROME 435.2 SUBCLAVIAN STEAL SYNDROME 435.9 UNSPECIFIED TRANSIENT CEREBRAL ISCHEMIA 437.3 CEREBRAL ANEURYSM NONRUPTURED 442.81 ANEURYSM OF ARTERY OF NECK 442.82 ANEURYSM OF SUBCLAVIAN ARTERY - 8 -
443.21 DISSECTION OF CAROTID ARTERY 443.24 DISSECTION OF VERTEBRAL ARTERY 446.7 TAKAYASU'S DISEASE 447.0 ARTERIOVENOUS FISTULA ACQUIRED 447.1 STRICTURE OF ARTERY 447.2 RUPTURE OF ARTERY 447.5 NECROSIS OF ARTERY 447.8 OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES 747.81 CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM 780.2 SYNCOPE AND COLLAPSE 780.4 DIZZINESS AND GIDDINESS 781.99* OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEMS 784.2 SWELLING MASS OR LUMP IN HEAD AND NECK 793.0 NONSPECIFIC (ABNORMAL) FINDINGS ON RADIOLOGICAL AND OTHER EXAMINATION OF SKULL AND HEAD 852.00 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED 852.01 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS 852.02 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS 852.03 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS 852.04 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL 852.05 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL 852.06 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION 852.09 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED 852.10 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED 852.11 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS 852.12 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS 852.13 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS - 9 -
852.14 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL 852.15 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL 852.16 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION 852.19 SUBARACHNOID HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED 852.20 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED 852.21 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS 852.22 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS 852.23 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS 852.24 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL 852.25 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL 852.26 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION 852.29 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED 852.30 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED 852.31 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS 852.32 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS 852.33 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS 852.34 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL 852.35 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL 852.36 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION 852.39 SUBDURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED - 10 -
852.40 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED 852.41 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS 852.42 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN 1 HOUR) LOSS OF CONSCIOUSNESS 852.43 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS 852.44 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL 852.45 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL 852.46 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION 852.49 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITHOUT OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED 852.50 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH STATE OF CONSCIOUSNESS UNSPECIFIED 852.51 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH NO LOSS OF CONSCIOUSNESS 852.52 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH BRIEF (LESS THAN ONE HOUR) LOSS OF CONSCIOUSNESS 852.53 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH MODERATE (1-24 HOURS) LOSS OF CONSCIOUSNESS 852.54 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS AND RETURN TO PRE-EXISTING CONSCIOUS LEVEL 852.55 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH PROLONGED (MORE THAN 24 HOURS) LOSS OF CONSCIOUSNESS WITHOUT RETURN TO PRE- EXISTING CONSCIOUS LEVEL 852.56 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH LOSS OF CONSCIOUSNESS OF UNSPECIFIED DURATION 852.59 EXTRADURAL HEMORRHAGE FOLLOWING INJURY WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED 900.00 INJURY TO CAROTID ARTERY UNSPECIFIED 900.01 INJURY TO COMMON CAROTID ARTERY 900.02 INJURY TO EXTERNAL CAROTID ARTERY 900.03 INJURY TO INTERNAL CAROTID ARTERY 900.82 INJURY TO MULTIPLE BLOOD VESSELS OF HEAD AND NECK 900.89 INJURY TO OTHER SPECIFIED BLOOD VESSELS OF HEAD AND NECK 908.3 LATE EFFECT OF INJURY TO BLOOD VESSEL OF HEAD NECK AND EXTREMITIES - 11 -
996.1 MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT 996.2 MECHANICAL COMPLICATION OF NERVOUS SYSTEM DEVICE IMPLANT AND GRAFT 781.99* - Use for patients presenting with signs and symptoms strongly suggesting an intracerebral aneurysm, without the MRA finding of an aneurysm. - 12 -
MRA of the Lower Extremities 228.09 HEMANGIOMA OF OTHER SITES 250.70 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, NOT STATED AS UNCONTROLLED 250.71 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], NOT STATED AS UNCONTROLLED 250.72 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE II OR UNSPECIFIED TYPE, UNCONTROLLED 250.73 DIABETES WITH PERIPHERAL CIRCULATORY DISORDERS, TYPE I [JUVENILE TYPE], UNCONTROLLED 440.20 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES UNSPECIFIED 440.21 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH INTERMITTENT CLAUDICATION 440.22 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH REST PAIN 440.23 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH ULCERATION 440.24 ATHEROSCLEROSIS OF NATIVE ARTERIES OF THE EXTREMITIES WITH GANGRENE 440.30 ATHEROSCLEROSIS OF UNSPECIFIED BYPASS GRAFT OF THE EXTREMITIES 440.31 ATHEROSCLEROSIS OF AUTOLOGOUS VEIN BYPASS GRAFT OF THE EXTREMITIES 440.32 ATHEROSCLEROSIS OF NONAUTOLOGOUS BIOLOGICAL BYPASS GRAFT OF THE EXTREMITIES 442.2 ANEURYSM OF ILIAC ARTERY 442.3 ANEURYSM OF ARTERY OF LOWER EXTREMITY 443.1 THROMBOANGIITIS OBLITERANS (BUERGER'S DISEASE) 443.22 DISSECTION OF ILIAC ARTERY 443.29 DISSECTION OF OTHER ARTERY 443.81 PERIPHERAL ANGIOPATHY IN DISEASES CLASSIFIED ELSEWHERE 443.9 PERIPHERAL VASCULAR DISEASE UNSPECIFIED 444.22 ARTERIAL EMBOLISM AND THROMBOSIS OF LOWER EXTREMITY 444.81 EMBOLISM AND THROMBOSIS OF ILIAC ARTERY 444.89 EMBOLISM AND THROMBOSIS OF OTHER ARTERY 445.02 ATHEROEMBOLISM OF LOWER EXTREMITY 447.1 STRICTURE OF ARTERY 447.5 NECROSIS OF ARTERY 447.6 ARTERITIS UNSPECIFIED 447.8 OTHER SPECIFIED DISORDERS OF ARTERIES AND ARTERIOLES 747.64 LOWER LIMB VESSEL ANOMALY 747.69 ANOMALIES OF OTHER SPECIFIED SITES OF PERIPHERAL VASCULAR SYSTEM 785.4 GANGRENE - 13 -
904.0 INJURY TO COMMON FEMORAL ARTERY 904.1 INJURY TO SUPERFICIAL FEMORAL ARTERY 904.41 INJURY TO POPLITEAL ARTERY 904.51 INJURY TO ANTERIOR TIBIAL ARTERY 904.53 INJURY TO POSTERIOR TIBIAL ARTERY 996.1 MECHANICAL COMPLICATION OF OTHER VASCULAR DEVICE IMPLANT AND GRAFT V67.00 FOLLOW-UP EXAMINATION FOLLOWING UNSPECIFIED SURGERY V67.59 OTHER FOLLOW-UP EXAMINATION - 14 -