ICD-10 Codes covered under Medical Nutrition Therapy services – Effective February 1, 2021*

ICD-10 Diagnosis Code Description ICD-10 Diagnosis Code Description A56.01 Chlamydial cystitis and E24.0 Pituitary-dependent Cushing's disease Congenital adrenogenital disorders associated B20. HIV E25.0 with enzyme deficiency B52.0 Plasmodium malariae malaria with nephropathy E20.1 Pseudohypoparathyroidism B25.1 Cytomegaloviral hepatitis E28.2 Polycystic Ovarian Syndrome B25.2 Cytomegaloviral pancreatitis E34.0 Carcinoid syndrome B52.0 Plasmodium malariae malaria with nephropathy E41 Nutritional C00.0 – C96.9 All types of Cancer code (range) E42 Marasmic C96.A Histiocytic sarcoma E43 Unspecified severe protein-calorie Other specified malignant neoplasms of C96.Z lymphoid, hematopoietic and related tissue E44.0 – E46 Moderate protein-calorie malnutrition (range) D00.00 – D09.9 Carcinoma code (range) E50 – E50.9 A deficiency (range) D63.0 Anemia in neoplastic disease E51 – E51.9 (range) D64.81 Anemia due to antineoplastic chemotherapy E52 Niacin deficiency [] Agranulocytosis secondary to cancer D70.1 E53.0 – E53.9 Deficiency of other B group (range) chemotherapy E54 Ascorbic acid deficiency D70.2 Other drug-induced agranulocytosis E55.0 – E55.9 anemia secondary to blood loss D50.0 – D50.1 (range) E56.0 – E56.9 Other vitamin deficiencies D50.8 – D50.9 Other iron Deficiency Anemia (range) E58 Dietary calcium deficiency D51.0 – D51.9 B12 deficiency anemia (range) E59 Dietary D52.0 – D52.9 Dietary folate anemia (range) E60 Dietary D53.0 – D53.9 Other anemia (range) E61.0 – E61.9 Deficiency of other nutrient elements D55.0 – D55.9 Anemia due to enzyme disorders (range) E63.0 – E63.9 Other nutritional deficiencies D64.81 Anemia due to antineoplastic chemotherapy E64.0 – E64.9 Sequelae of protein-calorie malnutrition (range) D64.89 Other specified anemias E65 Localized adiposity D64.9 Anemia US E66.0 – E66.9 Obesity (code range) Other disorders involving the immune mechanism, D89.0-D89.2 E67.0 – E67.8 Other hyperalimentation (code range) not elsewhere classified (code range) E68 Sequelae of hyperalimentation E03.9 Hypothyroidism Disorders of aromatic amino acid metabolism/ E70.0 – E70.9 E05.90 Thyrotoxicosis PKU (code range) Disorders of branched chain amino acid E08 – E13.9 All Diabetes code range E71.0 – E71.39 metabolism (code range) E08.00 – E08.9 Diabetes due to underlying conditions (range) E71.40 – E71.43 Disorders of carnitine metabolism E09.00 – E09.9 Drug induced diabetes mellitus (range) E71.440 Ruvalcaba-Myhre-Smith syndrome E10.10 – E10.9 Type 1 Diabetes (range) E71.448 Other secondary carnitine deficiency E11.00 – E11.9 Type 2 Diabetes (range) Disorders of amino acid transport/ E72.00 – E72.9 E13.00 – E13.9 Other specified diabetes(range) homocystinuria (code range) E16.0 – E16.2 Hypoglycemia (range) E73.0 – E73.9 Lactose intolerance (code range) Other disorders of carbohydrate metabolism E20.1 Pseudohypoparathyroidism E74.00 – E74.9 (code range) E22.0 Acromegaly and pituitary gigantism

*This list of diagnoses is subject to change. PRV20473-2101 ICD-10 Codes covered under Medical Nutrition Therapy services – Effective February 1, 2021*

ICD-10 Diagnosis Code Description ICD-10 Diagnosis Code Description E75.21 – E75.249 Other sphingolipidosis (code range) Localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex G40.201 E75.3 Sphingolipidosis, unspecified partial seizures, not intractable, with status E75.5 – E75.6 Other lipid storage disorders (code range) epilepticus Localization-related (focal) (partial) symptomatic E77.0 – E77.9 Disorders of glycoprotein metabolism (code range) epilepsy and epileptic syndromes with complex G40.209 Disorders of lipoprotein metabolism and other partial seizures, not intractable, without status E78.7 – E78.9 lipidemias (code range) epilepticus Disorders of porphyrin and bilirubin metabolism Localization-related (focal) (partial) symptomatic E80.0 – E80.29 (code range) epilepsy and epileptic syndromes with complex G40.211 partial seizures, intractable, with status E83.00 – E83.19, Disorders of mineral metabolism (code range) epilepticus E83.30 – E83.9 Localization-related (focal) (partial) symptomatic E84.0 – E84.9 Cystic fibrosis (range) epilepsy and epileptic syndromes with complex G40.219 E86.0 – E86.9 Volume depletion (code range) partial seizures, intractable, without status epilepticus Other disorders of fluid electrolyte and acid- E87.0 – E87.8 base balance (code range) Generalized idiopathic epilepsy and epileptic G40.301 – G40.309 syndromes, not intractable, with status E88.01 – E88.2, Other and unspecified metabolic disorders epilepticus (range) E88.89 (code range) E88.3 Tumor lysis syndrome Generalized idiopathic epilepsy and epileptic G40.311 – G40.319 syndromes, intractable, with status epilepticus Absence epileptic syndrome, not intractable, (range) G40.A01 – G40.A09 with status epilepticus (range) Other generalized epilepsy and epileptic Absence epileptic syndrome, intractable, with G40.A11 – G40.A19 G40.401 – G40.409 syndromes, not intractable, with status status epilepticus (range) epilepticus (range) Juvenile myoclonic epilepsy, not intractable, Other generalized epilepsy and epileptic G40.B01 – G40.B09 G40.411 with status epilepticus (range) syndromes, intractable, with status epilepticus Juvenile myoclonic epilepsy, intractable, with G40.B11 Other generalized epilepsy and epileptic status epilepticus G40.419 syndromes, intractable, without status Juvenile myoclonic epilepsy, intractable, without epilepticus G40.B19 status epilepticus Epileptic seizures related to external causes, not G40.501 Localization-related (focal) (partial) idiopathic intractable, with status epilepticus epilepsy and epileptic syndromes with seizures G40.001 Epileptic seizures related to external causes, not of localized onset, not intractable, with status G40.509 intractable, without status epilepticus epilepticus Other epilepsy, not intractable, with status Localization-related (focal) (partial) idiopathic G40.801 – G40.804 epilepticus (range) epilepsy and epileptic syndromes with seizures G40.009 Lennox-Gastaut syndrome, not intractable, with of localized onset, not intractable, without status G40.811 – G40.814 epilepticus status epilepticus Epileptic spasms, not intractable, with status Localization-related (focal) (partial) idiopathic G40.821 – G40.89 epilepsy and epileptic syndromes with seizures epilepticus (range) G40.011 – G40.019 of localized onset, intractable, with status Epilepsy, unspecified, not intractable, with status G40.901 epilepticus (range) epilepticus Localization-related (focal) (partial) symptomatic Epilepsy, unspecified, not intractable, without epilepsy and epileptic syndromes with simple G40.909 G40.101 – G40.109 status epilepticus partial seizures, not intractable, with status epilepticus (range) G40.911 – G40.919 Epilepsy Localization-related (focal) (partial) symptomatic G47.30 Sleep apnea, unspecified epilepsy and epileptic syndromes with simple G40.111 – G40.119 partial seizures, intractable, with status G47.33 Obstructive sleep apnea (adult) (pediatric) epilepticus (range) I09.81 Rheumatic heart failure I10 – I16.9 Hypertension/ HTN kidney disease/Crisis (range)

PRV20473-2101 ICD-10 Codes covered under Medical Nutrition Therapy services – Effective February 1, 2021*

ICD-10 Diagnosis Code Description ICD-10 Diagnosis Code Description Acute coronary thrombosis not resulting in I24.0 – I25.9 K29.80 – K29.81 Duodenitis without bleeding myocardial infarction (range) K29.90 Gastroduodenitis, unspecified, without bleeding Atherosclerotic heart disease of native coronary I25.10 artery without angina pectoris K29.91 Gastroduodenitis, unspecified, with bleeding I27.0 – I 27.2 Primary pulmonary hypertension (range) K30.0 Functional dyspepsia I27.81 Cor pulmonale (chronic) K31.0 Acute dilatation of stomach I27.82 Chronic pulmonary embolism K31.1 Adult hypertrophic pyloric stenosis I27.83 Eisenmenger's syndrome K31.2 Hourglass stricture and stenosis of stomach I27.89 Other specified pulmonary heart diseases K31.3 Pylorospasm, not elsewhere classified I27.9 Pulmonary heart disease, unspecified K31.4 Gastric diverticulum I42.2 – I43 Other hypertrophic cardiomyopathy (range) K31.5 Obstruction of duodenum I50.1 – I50.9 Heart failure (range) K31.6 of stomach and duodenum Angiodysplasia of stomach and duodenum with I51.4 Myocarditis, unspecified K31.811 – K31.9 bleeding I51.5 – I51.7 Cardiomegaly K44.0 – K44.9 Diaphragmatic hernia (range) I51.9 Heart disease, unspecified Crohn's disease of small intestine without Other heart disorders in diseases classified K50.00 I52 complications elsewhere Crohn's disease of large intestine without Other specified noninfective disorders of K50.10 I89.8 complications lymphatic vessels and lymph nodes (chylous) Crohn's disease of small intestine with rectal K50.011 – K50.019 I97.3 Postprocedural hypertension bleeding Crohn's disease of large intestine with rectal J94.0 Chylous effusion K50.111 – K50.119 bleeding Oral mucositis (ulcerative) due to antineoplastic K12.31 Crohn's disease of both small and large therapy K50.80 intestine without complications K12.33 Oral mucositis (ulcerative) due to radiation Crohn's disease of both small and large K50.811 – K50.819 K20.0 Eosinophilic esophagitis intestine with rectal bleeding Crohn's disease, unspecified, without K21.0 GERD with esophagitis K50.90 complications K21.9 GERD w/o esophagitis K25 – K25.9 Gastric Ulcer K50.911 – K50.919 Crohn's disease Ulcerative (chronic) pancolitis without K26.0 – K26.9 Acute duodenal ulcer with hemorrhage (range) K51.00 complications K27.0 – K27.9 Peptic ulcer Ulcerative (chronic) pancolitis with rectal K51.011 – K51.019 K28.0 – 528.9 Gastrojejunal ulcer bleeding K29.00 – K29.01 Acute gastritis without bleeding Ulcerative (chronic) proctitis without K51.20 complications K29.20 – K29.21 Alcoholic Gastritis K51.211 – K51.219 Ulcerative (chronic) proctitis with rectal bleeding K29.30 – K29.31 Chronic superficial gastritis without bleeding Ulcerative (chronic) rectosigmoiditis without K51.30 K29.40 Chronic atrophic gastritis without bleeding complications K29.41 Chronic atrophic gastritis with bleeding K51.311 – K51.319 Ulcerative (chronic) rectosigmoiditis K29.50 – K29.51 Unspecified chronic gastritis Inflammatory polyps of colon without K51.40 complications K29.60 – K29.61 Other gastritis without bleeding Inflammatory polyps of colon with rectal K51.411 – K51.419 K29.70 – K29.71 Gastritis US bleeding

*This list of diagnoses is subject to change. PRV20473-2101 ICD-10 Codes covered under Medical Nutrition Therapy services – Effective February 1, 2021*

ICD-10 Diagnosis Code Description ICD-10 Diagnosis Code Description Diverticulitis of both small and large intestine K51.50 Left sided colitis without complications K57.41 with perforation and abscess with bleeding K51.511 – K51.519 Left sided colitis Diverticulitis of small intestine with perforation K57.01 K51.80 Other ulcerative colitis without complications and abscess with bleeding Diverticulosis of small intestine without K51.811 – K51.819 Other ulcerative colitis with rectal bleeding K57.10 – K57.13 perforation or abscess without bleeding Ulcerative colitis, unspecified, without K51.90 Diverticulitis of large intestine with perforation complications K57.21 and abscess with bleeding Ulcerative colitis, unspecified with rectal K51.911 – K51.919 bleeding K57.30 – K57.33 Diverticulitis of large intestine K52.0 – K52.2 Gastroenteritis and colitis due to radiation Diverticulitis of both small and large intestine K57.41 K52.21 Food protein-induced enterocolitis syndrome with perforation and abscess with bleeding Diverticulosis of both small and large intestine K52.2 Allergic and dietetic gastroenteritis and colitis K57.50 without perforation or abscess without bleeding K52.22 Food protein-induced enteropathy Diverticulosis of both small and large intestine Other allergic and dietetic gastroenteritis and K52.29 K57.51 without perforation or abscess colitis with bleeding K52.3 Indeterminate colitis Diverticulitis of both small and large K52.81 – K52.9 Eosinophilic gastritis or gastroenteritis (range) K57.52 intestine without perforation or abscess without bleeding K55.0 – K55.1 Acute (reversible) ischemia of small intestine Diverticulitis of both small and large intestine K57.53 K55.20 – K55.9 Angiodysplasia of colon without hemorrhage without perforation or abscess with bleeding K56.0 – K56.3 Paralytic ileus Diverticulitis of intestine, part unspecified, with K57.81 perforation and abscess with bleeding K56.41 – 56.49 Fecal impaction Diverticulosis of intestine, part unspecified, Intestinal adhesions [bands] with obstruction K57.90 K56.5 without perforation or abscess without bleeding (postinfection) Diverticulosis of intestine, part unspecified, K57.91 K56.60 Unspecified intestinal obstruction without perforation or abscess with bleeding Partial intestinal obstruction, unspecified as to Diverticulitis of intestine, part unspecified, K56.600 K57.92 cause without perforation or abscess without bleeding Complete intestinal obstruction, unspecified as Diverticulitis of intestine, part unspecified, K56.601 K57.93 to cause without perforation or abscess with bleeding Unspecified intestinal obstruction, unspecified K56.609 K58.0 – K58.9 Irritable bowel syndrome (range) as to partial versus complete obstruction K59.00 – K59.9 Constipation, unspecified (range) K56.69 Other intestinal obstruction K63.1 – K63.4 Perforation of intestine (nontraumatic) (range) K56.690 Other partial intestinal obstruction K63.81 – K63.9 Dieulafoy lesion of intestine (range) K56.691 Other complete intestinal obstruction K70.0 Alcoholic fatty liver Other intestinal obstruction unspecified as to K56.699 partial versus complete obstruction K70.3 Alcoholic cirrhosis of liver K56.7 Ileus, unspecified K71.0 Toxic liver disease with cholestasis K56.41 – K56.5 Fecal impaction Alcoholic hepatitis and alcoholic fibrosis and K70.10 – K70.2 sclerosis of liver (range) K56.60 – K56.7 Unspecified intestinal obstruction K70.30 – K70.31 alcoholic cirrhosis of liver Diverticulosis of small intestine wo perforation K57.01 or abscess K70.40 – K70.9 Alcoholic hepatic failure (range) Diverticulosis of large intestine wo perforation Toxic liver disease with chronic active hepatitis K57.1 – K57.3 K71.50 – K71.9 or abscess (range) K71.10 – K71.4 Toxic liver disease (range)

PRV20473-2101 ICD-10 Codes covered under Medical Nutrition Therapy services – Effective February 1, 2021*

ICD-10 Diagnosis Code Description ICD-10 Diagnosis Code Description Toxic liver disease with chronic active hepatitis K71.50 – K71.9 K86.9 Disease of pancreas, unspecified without ascites (range) Disorders of gallbladder, biliary tract and Acute and subacute hepatic failure K87 K72.00 – K72.01 pancreas in diseases classified elsewhere without coma K90.0 – K90.4 Celiac disease K72.10 – K72.11 Chronic hepatic failure without coma K90.89 – K90.9 Other intestinal malabsorption K72.90 – K72.91 Hepatic failure, unspecified without coma K91.0 – K91.2 Vomiting following gastrointestinal surgery K73.0 – K73.9 Chronic hepatitis K91.5 Postcholecystectomy syndrome K74.0 – K74.5 Hepatic fibrosis K91.850 Pouchitis K74.60 – K74.69 Unspecified cirrhosis of liver K91.858 Other complications of intestinal pouch K75.0 – K75.4 Abscess of liver Other postprocedural complications and K91.89 K75.81 – K75.9 Nonalcoholic steatohepatitis (NASH) disorders of digestive system K76.0 Fatty (change of) liver, not elsewhere classified K92.0 – K92.2 Hematemesis K76.1 Chronic passive congestion of liver K92.81 Gastrointestinal mucositis (ulcerative) K76.2 Central hemorrhagic necrosis of liver K92.89 – K92.9 Other specified diseases of the digestive system K76.3 Infarction of liver K94.00 – K94.09 Colostomy K76.4 Peliosis hepatis K94.10 – K94.19 Enterostomy complication, unspecified K76.5 Hepatic veno-occlusive disease K94.20 – K94.29 Gastrostomy complication, unspecified K76.6 Portal hypertension M1A.3 Chronic Gout d/t renal impairment K76.7 Hepatorenal syndrome M1A.9 Chronic Gout US K76.81 – K77 Hepatopulmonary syndrome M10.3 Gout d/t renal impairment Calculus of gallbladder with acute cholecystitis K80.00 – K80.01 M10.4 Other secondary Gout without obstruction M10.9 Gout US Calculus of gallbladder with chronic cholecystitis K80.10 – K80.19 Glomerular disease in systemic lupus without obstruction M32.14 – M32.15 erythematosus Calculus of gallbladder without cholecystitis K80.20 – K80.21 Sicca syndrome with tubulo-interstitial without obstruction M35.04 nephropathy K80.30 – K80.33 Calculus of bile duct with cholangitis M81.0 Osteoporosis, age related w/o fracture K80.35 – K80.81 Calculus of bile duct (range) M81.8 Other osteoporosis w/o fracture K81.0 – K81.9 Acute cholecystitis Acute nephritic syndrome with minor glomerular N00.0 – N00.9 K82.0 – K82.9 Obstruction of gallbladder abnormality K83.0 – K83.9 Primary sclerosing cholangitis N01.0 – N21.9 Kidney diseases and syndromes (range) K85.0 – K85.9 Acute pancreatitis N01 Rapidly progressive nephritic syndrome K86.0 Alcohol-induced chronic pancreatitis N02 Hematuria with glomercular abnormality K86.1 Other chronic pancreatitis N03 Chronic nephritic syndrome K86.2 Cyst of pancreas N04 K86.3 Pseudocyst of pancreas N05 Unspecified nephritic syndrome K86.8 Other specified diseases of pancreas N06 Glomerulonephritis K86.81 Exocrine pancreatic insufficiency N07 Nephropathy K86.89 Other specified diseases of pancreas N08 Glomerular disorders

PRV20473-2101 ICD-10 Codes covered under Medical Nutrition Therapy services – Effective February 1, 2021*

ICD-10 Diagnosis Code Description ICD-10 Diagnosis Code Description N10 Acute pyelonephritis N36.41 – N36.8 Urethral functional disorders (range) N11 Pyelonephritis N37 Urethral disorders N12 Tubulo interstitial nephritis N39.0 Other disorders of N13 Hydronephrosis N39.8 Other specified disorders of urinary system Drug- and heavy-metal-induced N14 N91.2 Amenorrhea tubulo-interstitial and tubular conditions N99.110 – N99.12 Post procedural (range) N15 Other renal tubulo-interstitial diseases N99.510 – N99.518 Cystosomy hemorrhage (range) Renal tubulo-interstitial disorders in diseases N16 Pre-existing essential hypertension complicating classified elsewhere O10.011 – O10.03 pregnancy, first trimester (range) N17.0 – N17.9 AKF O10.111 – O10.13 Pre-existing hypertensive heart disease (range) N18.0 – N18.9 CKD Pre-existing hypertensive chronic kidney O10.211 – O10.23 N19 US kidney failure disease complicating pregnancy (range) N20.0 – N20.9 Calculus of kidney Pre-existing hypertensive heart and chronic O10.311 – O10.33 kidney disease complicating pregnancy, N21.0 Calculus of lower urinary tract childbirth and the puerperium (range) Calculus of urinary tract in diseases classified Pre-existing secondary hypertension N22 O10.411 – O10.43 elsewhere complicating pregnancy (range) N25.0 Renal osteodystrophy Unspecified pre-existing hypertension O10.911 – O10.93 N25.1 Nephrogenic diabetes insipidus complicating pregnancy (range) Other disorders resulting from impaired renal Pre-existing hypertension with pre-eclampsia N25.81 – N35.014 O11.0 – O11.9 tubular function (range) (range) N27.0-N27.9 Small kidney (range) O12.10 – O12.13 Gestational proteinuria (range) N28.0 Ischemia and infarction of kidney O12.20 – O12.23 Gestational edema with proteinuria (range) Gestational [pregnancy-induced] hypertension N28.1 Cyst of kidney, acquired O13.1 – O13.9 without significant proteinuria (range) N30.20 – N30.21 Other chronic cystitis (range) O14.00 – O14.03 Mild to moderate pre-eclampsia (range) N30.30 – N30.31 (range) O14.10 – O14.13 Severe pre-eclampsia (range) Uninhibited neuropathic bladder, not elsewhere N31.0 O14.20 – O14.23 HELLP syndrome (range) classified Reflex neuropathic bladder, not elsewhere O14.90 – O14.93 Unspecified pre-eclampsia (range) N31.1 classified O15.00 – O15.03 Eclampsia complicating pregnancy (range) Flaccid neuropathic bladder, not elsewhere N31.2 O15.2 – O15.9 Eclampsia complicating labor (range) classified N31.8 Other neuromuscular dysfunction of bladder O16.1 – O16.9 Unspecified maternal hypertension (range) Neuromuscular dysfunction of bladder, Pre-existing type 1 diabetes mellitus, in N31.9 O24.011 – O24.33 unspecified pregnancy (range) Gestational diabetes mellitus in pregnancy N32.0 Bladder-neck obstruction O24.410 – O24.419 (range) N32.1 Vesicointestinal fistula Gestational diabetes mellitus in pregnancy O24.420 – O24.429 N32.2 Vesical fistula, not elsewhere classified (range) Gestational diabetes mellitus in the puerperium, N32.3 Diverticulum of bladder O24.430 – O24.439 diet controlled (range) N35.021 – N35.028 Range post traumatic urethral stricture (range) Other pre-existing diabetes mellitus in O24.811 – O24.93 N35.111 – N35.9 post-infective urethral stricture (range) pregnancy (range) Pregnancy related renal disease, first trimester N36.0 – N36.2 Disorders of (range) O26.831 – O26.839 (range)

PRV20473-2101 ICD-10 Codes covered under Medical Nutrition Therapy services – Effective February 1, 2021*

ICD-10 Diagnosis Code Description ICD-10 Diagnosis Code Description Other complications of the puerperium, not O90.89 R11 Nausea and vomiting elsewhere classified R11.10 Vomiting, unspecified O99.210 – O99.215 Obesity complicating pregnancy (range) R11.13 Vomiting of fecal matter Abnormal glucose complicating pregnancy O99.810 – O99.815 (range) R14.0 Abdominal distention Congenital absence, atresia and stenosis of Q41.0 – Q41.9 R31.0 – R31.9 Hematuria duodenum (range) R56.9 Unspecified convulsions Congenital absence, atresia and stenosis of Q42.0 – Q42.9 with fistula (range) R62.0 Delayed milestone in childhood Other congenital malformations of intestine Unspecified lack of expected normal physiological Q43.0 – Q43.9 R62.50 – R62.59 (range) development in childhood/ Q44.0 Agenesis, aplasia and hypoplasia of gallbladder R63.0 Q44.1 Other congenital malformations of gallbladder R63.3 Feeding difficulties Q44.2 Atresia of bile ducts R63.4 Abnormal Q44.3 Congenital stenosis and stricture of bile ducts R63.5 Abnormal weight gain Q44.4 Choledochal cyst R63.6 Q44.5 Other congenital malformations of bile ducts R73.01 Impaired fasting glucose Q44.6 Cystic disease of liver R73.02 Impaired glucose tolerance test oral Q44.7 Other congenital malformations of liver R73.03 Prediabetes Q62.0 Congenital hydronephrosis R73.09 Other abnormal glucose Q45.0 Agenesis, aplasia and hypoplasia of pancreas R73.9 Hypergylcemia Agenesis, aplasia and hypoplasia of pancreas R80.2 Orthostatic proteinuria, unspecified Q45.0 – Q45.9 (range) Encounter for follow-up examination after Z08 Q45.1 Annular pancreas completed treatment for malignant neoplasm Encounter for aftercare following bone marrow Q45.2 Congenital pancreatic cyst Z48.290 transplant Other congenital malformations of pancreas and Q45.3 pancreatic duct Z51.0 Encounter for antineoplastic radiation therapy Other specified congenital malformations of Z51.11 Encounter for antineoplastic chemotherapy Q45.8 digestive system Z51.12 Encounter for antineoplastic immunotherapy Congenital malformation of digestive system, Q45.9 unspecified Z68.1 BMI 19 or less Q60.0 Renal agenesis Z68.25 – Z68.29 Body mass index (BMI) adult, 25.0 – 29.9 kg. Body mass index (BMI) adult, 30.0 – 40+kg Q61.00 – Q61.02 Congenital renal cyst (range) Z68.30 – Z68.45 obesity (range) Q61.11 – Q61.9 Polycystic kidney, infantile type (range) Z68.51 BMI, pediatric, less than 5% for age Q62.0 Congenital hydronephrosis BMI pediatric, 5th percentile to less than 85% Z68.52 Q62.10 Congenital occlusion of , unspecified for age (claims data) Body mass index (BMI) pediatric, 85th percentile Q62.11 Congenital occlusion of ureteropelvic junction Z68.53 to less than 95th percentile for age Q62.12 Congenital occlusion of ureterovesical orifice Body mass index (BMI) pediatric, greater than or Z68.54 Q62.2 Congenital equal to 95th percentile for age Dietary Counseling and surveillance (Top code Q62.31 – Q62.39 Congenital (range) Z71.3 submitted, 6k) Q63.0 – Q63.9 Accessory kidney (range)

PRV20473-2101 ICD-10 Codes covered under Medical Nutrition Therapy services – Effective February 1, 2021*

ICD-10 Diagnosis Code Description ICD-10 Diagnosis Code Description Z72.4 Inappropriate diet and eating habits Z94.3 Heart and lungs transplant status Z93.1 Gastrostomy status Z94.4 Liver transplant status Z94.0 Kidney Transplant Z94.82 Intestine transplant status Z94.1 Heart transplant status Z94.83 Pancreas transplant status Z94.2 Lung transplant status Z98.84 Bariatric surgery status

*This list of diagnoses is subject to change.

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PRV20473-2101