Billing Manual

BILLING GUIDE for Laboratory Test Requisitions

Provided for the clients of

P ATHOLOGY ASSOCIATES MEDICAL LABORATORIES P ACL AB NETWORK LABORATORIES T RI-CITIES LABORATORY T REASURE VALLEY LABORATORY A LPHA MEDICAL LABORATORY For more information, please contact your local representative.

2 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 Contents

SECTION 1 29 Outpatient Diagnostic Coding & Reporting Guidelines

5 Introduction 29 Outpatient Coding Guidelines

5 How Our Billing Expertise Can Help You 32 Customized ICD·9 Requisition Policy

5 The Importance of Diagnosis Codes 33 Customized ICD·9 Requisition Request Form

34 Customized ICD·9 Requisition Sample SECTION 2

7 Client Billing SECTION 7

9 Successful Laboratory Requisitions, Client Billing 43 Medicare Billing

45 Successful Laboratory Requisitions, Medicare Billing

SECTION 3 46 Medicare Waivers

11 Insurance Billing 47 Advance Beneficiary Notice

13 Successful Laboratory Requisitions, Insurance Billing 48 Advance Beneficiary Notice Sample

14 Unusual & Important Information on Specific Insurance Carriers 49 Medicare Secondary Payer

16 Requirements of Specific Insurance Companies 50 Medicare Secondary Payer Questions

51 Tests Requiring Proof of Medical Necessity ID Medicare B

SECTION 4 52 Tests Requiring Proof of Medical Necessity WA Medicare A1

21 Washington Public Assistance 53 Tests Requiring Proof of Medical Necessity WA Medicare A2

23 Successful Laboratory Requisitions, WA Public Assistance Billing 54 Tests Requiring Proof of Medical Necessity WA Medicare B

SECTION 5 SECTION 8

25 Washington Healthy Options 55 LMRPs – Idaho Medicare

27 Successful Laboratory Requisitions, Healthy Option Billing 56 Warranty and Liability Disclaimer

28 Sample Medical Assistance ID (MAID) Card With HIC Number

28 Sample Medical Assistance ID (MAID) Healthy Options Card SECTION 9

29 Healthy Options and Managed Care 71 LMRPs – Washington Medicare A

72 Warranty and Liability Disclaimer SECTION 6

31 Correct Coding SECTION 10

32 Top Ten Most Common Invalid ICD·9 Codes 79 LMRPs – Washington Medicare B

34 ICD·9 Coding Diagnostic Requirements 80 Warranty and Liability Disclaimer

35 ESRD Claims and Diagnoses

SEPTEMBER 2000 3 (509) 927-6250 • 1-800-433-1583

4 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 INTRODUCTION Introduction

How Our Billing Expertise Can Help You

■ Extensive relationships with payers throughout the region; including most electronic billing systems.

■ ICD·9 coding education available.

■ Periodic test mix summaries illustrating utilization of lab procedures by physicians.

■ Convenient, professional direct billing available for your patients.

■ Reports detailing patient charges including procedure, bill type, and cost.

■ Local, in-state billing staff with convenient toll-free service.

The Importance of Diagnosis Codes

In today’s regulated health care climate, ICD·9 diagnosis codes are becoming mandatory. When requisitions arrive without an acceptable code or a signed waiver, we might not be reimbursed for our services. Please assist us by providing this required information at the time you order a test, and we’ll all save time and frustration. If you have any questions regarding this issue, please contact your service representative or the laboratory billing department.

We are pleased to provide various tools designed to help you. These include staff training, laminated diagnosis code quick-reference cards, waiver forms, waiting room signs, etc.

SEPTEMBER 2000 5 INTRODUCTION (509) 927-6250 • 1-800-433-1583

ICD-9 Coding Support. We can provide support for your ICD·9 coding efforts. Assistance in this increasingly vital area includes staff training, laminated diagnosis code quick- reference cards, waiver forms, waiting room signs, and more.

We have the Dedicated Billing Professionals. Knowledgeable billing professionals are always accessible. Beyond the convenience of experience, resources, ready access to assistance, clients have the assurance that comes from decades of experience with payers operating in and technology to help Washington and throughout the Pacific Northwest.

Experience Where It Counts. Our billing professionals have both you and your the depth and breadth of experience that makes a difference. In fact, our billing employees average eight years with the de- patients navigate partment. the increasingly Extensive Payer Relationships. We provide support to your patients by billing a wide variety of insurance companies complex billing directly. In an effort to serve our clients even better, we con- tinually monitor patient usage patterns of various carriers and environment. their associated programs, adding to the list of insurers billed on an ongoing basis.

Toll-Free Phone Support. Providing service throughout Washington and the Pacific Northwest, members of the laboratory billing team are available to you and your patients via our toll-free number.

Ethical Billing Standards. As a member of the Sisters of Providence family, PAML is pledged to adhere to the strictest code of billing ethics.

6 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 CLIENT BILLING

Client Billing

SEPTEMBER 2000 7 CLIENT BILLING (509) 927-6250 • 1-800-433-1583

8 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 CLIENT BILLING Client Billing

When you would like us to bill directly to your office

Successful Laboratory Requisitions, Client Billing

Would you like us to bill you (clinician) directly for these services, and not your patients or their insurance?

1. Circle DR/HOSP/CLINIC in the Bill To: section of the requisition.

Do not provide patient billing demographics, such as address and billing information.

SEPTEMBER 2000 9 CLIENT BILLING (509) 927-6250 • 1-800-433-1583

10 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 INSURANCE BILLING

Insurance Billing

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1 7 7 7

2 3 4

9 5 10 6 11

12 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 INSURANCE BILLING Insurance Billing

When you would like us to bill the patient or insurance company directly.

Successful Laboratory Requisitions, Insurance Billing

The following insurance company billing requirements will assist you to accurately complete laboratory requisitions. The objective is to minimize recurring phone calls to our valued clients and service center employees. Thank you for your attention to detail.

When billing insurance companies, the following information is Please provide an ICD-9 Code always required on the laboratory requisition: for every patient encounter. 1. Patient’s full name

2. Patient’s sex

3. Patient’s date of birth

4. Patient phone number

5. Responsible party’s name (if not patient)

6. Responsible party’s full address

7. Date and time of collection and fasting status

8. Whom is to be billed (Circle patient, doctor, Medicare, PA, or other) Additional information may be 9. Patient’s Social Security Number unique to specific insurances. Please review the requirements of 10. Insurance company name the enclosed primary insurance 11. Insurance ID number companies that we bill. 12. Insurance group number

13. Test ordered checked with proper and valid ICD·9 noted beside

14. Attached copy of insurance card, front and back

SEPTEMBER 2000 13 INSURANCE BILLING (509) 927-6250 • 1-800-433-1583

Unusual and Important Information on Specific Insurance Carriers

Reminder: Patient’s Full Demographics – including SSN, address, date of birth, phone number, guarantor, and complete insurance information and numbers are required for all requests to bill insurance. Please provide an ICD·9 code for each laboratory procedure requested.

Washington Public Assistance

■ Provide Healthy Options or private health-care information when HMO column is marked on coupon.

■ Provide Medicare information when HIC is marked on coupon.

■ Always provide copy of patient insurance cards and DSHS coupon.

Regence and other Blue Shields

■ Diagnosis code(s) are required.

■ Claims cannot be submitted to the insurer without a code.

■ Include 3-letter alpha prefix on insurance numbers.

■ Provide group number and county name (e.g., Whatcom).

First Choice Network and N.E.I.C. Clearinghouse

■ Provide insurance number, group number and insurance company name.

■ Provide front and back copies of insurance card.

Medicare

■ Diagnosis code(s) are critical.

■ Provide patient’s complete Medicare number.

■ Obtain a waiver if the test may be denied as medically unnecessary.

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Labor & Industries

■ We bill state and self-funded plans.

■ Provide SSN, claim number, date of injury, nature of injury, and employer at time of injury.

Group Health Cooperative

■ Diagnosis code(s) are required.

■ Provide patient’s Medical Record Number.

■ Provide patient’s Social Security Number.

Premera (Blue Cross and MSC) Physicians Health Network (PHN) NW Physicians Network (NPN) Pro Health Alliance (PHA) Prime Net Pierce Unicare Lewis County MSO Managed Care Specialist Referrals Private Health Care Systems (PHCS)

■ Please ALWAYS indicate when a patient is covered under one of the above provider networks. Provide the name of the network as indi- cated above, patient insurance number and group number, and the name of the insurance company or administrator (e.g., Blue Cross).

■ Provide copy of insurance card, front and back.

SEPTEMBER 2000 15 INSURANCE BILLING (509) 927-6250 • 1-800-433-1583

Requirements of Specific Insurance Companies

✔ A Third Party Administrator ✔ Blue Cross Basic Health ✔ Acordia Benefits of Northern CA ✔ Blue Cross Healthy Options (PBC) ✔ Accordia National ✔✗ Blue Cross of Idaho (XMB or XMP) ✔ Administar ✔ Blue Cross of Idaho HMO (XMH) (SPHCO) ✔ Administration & Ins. Office ✔ Blue Cross of Montana-Also Known As MPS (YDA) ✔ Administration Services Inc. ✔✗ Blue Cross of Wa. & AK (Co-Pay) ✔ Administrators West Inc. (Sound Health) ✔ Blue Cross Senior Partners ✔ Advanced Benefits Administrators (Sound Health) ✔ Blue Shield of Idaho (XNA or XNB) ✔ Adventist Risk Management Inc ✔ Board of Pensions ✔ Aetna Health Plans ✔ Boeing ✔ Aetna Health Ethix/WA Inc ✔ Boilmakers National Health & Welfare ✔ Aetna Life & Casualty Co. ✔ Boilermakers (IEBW) ✔ Aetna Medicare ✔ Boise ✔ Affordable Network ✔ Breast & Cervical Health Program (Pap smears only) ✔ Agency Services,Inc. (AS) ✔ Brokerage Service Inc. ✔ Alaska Care Health Plans ✔ Carestream ✔ Alaska Electrical Health & Welfare ✔ Carnation / Nestle Company ✔ Alaska Laborers ✔✗ Carpenters Trust of Eastern WA (INBA) ✔ Alaska Laborers (Group F23) ✔✗ Carpenters Trust of Western WA (1st Choice) ✔ Alaska Pipe Traders Local 375 (Group F24) ✔ Catholic Health Initiatives ✔ Alaska Union of Food ✔ CBSA ✔ Alaska United Food & Commercial (F45) ✔ Cement Masons & Plasterers Trust ✔ Alliant Plus Health Plan ✔ Cement Masons (Group F16 Only) ✔ Allmerica Financial Services ✔ Central ✔ Alta Health Strategies (First Health) ✔ Central Benefits Life ✔ American Benefits Plan Admin. Inc. ✔ Central Benefits Mutual ✔ American Chambers Life ✔ Central Benefits National ✔ American Healthcare Alliance ✔ Central Reserve Life ✔ American Medical Security ✔ Central Washington Health Plan ✔ Amr. Postal Workrs. Union Health Plan ✔ Centralia Mining Company ✔ Anchor Benefit Administrators ✔ Champva ✔ Anthem Benefit Servcs/Accordia Bnfts (1st Choice) ✔ Champus (Comment If Active Serv / Branch of Serv) ✔ Anthem Benefits ✔ Choice Option (Formerly Sound Alt.) (Select) ✔ Anthem Health (Select) ✔ Christian Bros EBT (Helena Diocese) (Health Infonet) ✔ Anthem Health ✔ Chubb Life America ✔ Aon Select (Health Infonet) ✔ Cigna ✔ Apollo Gold ✔ Cigna Health Plan ✔ Associated Admin, Inc. ✔✗ Cigna Medicare ✔ Associated Administrators (Sound Health) ✔ City of Bellevue ✔ Associated Administrators (Cpm Development) ✔ City of Bellingham ✔ Associates for Health Care ✔ Claims & Benefits ✔ ATPA (Pacific Maritime Association) ✔ Clallam County ✔ ATPA (International Assocation of Machinists) ✔✗ Classic Care (MSC) ✔ Aush (Aetna US Healthcare of Wa)(Healthy Options) ✔ Coalition America Inc. ✔ Automotive Machinists Local 289 (F32) ✔ Coastal Insurance Group ✔ AW Rehn & Associates ✔ Colville Confederated Tribes ✔ BCP (Benefit Claims Payer) ✔ Columbia Lighting ✔ Bakers Retirees Trust ✔ Commercial & Industrial ✔ Bankers United Life (Student Division) ✔ Commercial Carriers ✔ Bankers United Life ✔ Community Care Network (CCN) ✔ Basic American Foods (Sound Health) ✔ Comm for Ag ✔ Basic Health Plan ✔✗ Community Health Plan of WA (CHPW) ✔ Beech Street (normally a 10-digit member number) ✔ Confederated Life ✔ Bell Atlantic ✔ Connecticut General Life Ins. ✔ Benchmark Group ✔ Consolidated Group ✔ Benefit Design & Administrators ✔ Continental Assurance Company ✔ Benefit Plan Administrators ✔ Cooperative Benefits Admin. ✔ Benefit Resources ✔ Coresource ✔ Benefit Trust Life Ins. Co. ✔ Coresource,Inc. (Ethix) ✔ Berkley Risk Managers ✔ Corestar (Eagle Hardware & Garden)

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✔ Corporate Benefit Srvcs of America(Health Infonet) ✔ Hagen Benefit Administrators (Health Infonet) ✔ Costco ✔ Happy Guests International ✔ Crime Victims Claim number required. ✔ Harden & Company of Arizona ✔✗ CUP (Clark United Providers) (Healthy Options) ✔ Harrington Benefits ✔ DBL Services,Inc. ✔ Hartford ✔ Desert Mutual Benefit Admin. ✔ Hdr Employee Benefits ✔ Direct Administrators ✔ Health Benefit Administrators ✔ Disability Purchase order required. ✔✗ Health Care Authority ✔ Diversified Group Administrators (Sound Health) ✔ Healthcomp ✔ Diversified Group Brokerage ✔ Health Economics Corp. ✔ Drake Insurance Administrators ✔✗ Health First Partners ✔ Eagle Hardware & Garden (Corestar) ✔ Health Infonet ✔ Eagle Pacific Insurance Company (Ethix) ✔ Health Partners Inc. ✔✗ EDS (Idaho PA) ✔ Health Plans of America ✔ EDS Health Benefit Plan ✔✗ Health Plus ✔ EHI (Employers Health Insurance) ✔ Health Risk Management ✔ EHS (Employee Health Services) ✔ Healthsouth ✔ Eldec Corporation (UAI) ✔ Healthcare Mgt. Admin.,Inc. ✔ Eldorado Claims Services ✔ Healthrisk Mngmt (HRM) (Sound Health) ✔ Electrical Workers, Eastern & Western Washington ✔✗ Healthsense 65 (Blue Shield of Idaho) (XNA or XNB) ✔ Emp. Ben. Plans Ins. Svcs.,Inc. (1st Choice) ✔ Healthsource Provident Admin Insurance ✔ Employee Benefit Admin. & Mgt. ✔ Healthy Benefit Alliance ✔ Employee Benefit Mgt. Srvcs. (EBMS) ✔ Hecla Mining Co. ✔ Employee Benefit Plans (EBPE) ✔ Heller Associates ✔ Employee Benefit Plans (EBPM & EBPN) ✔✗ HIP Program (Disability) ✔ Employers Health Insurance ✔✗ HMO of Idaho ✔ Employee Benefit Mgt. Srvcs. ✔✗ HMO of Montana ✔ Employee Benefit Mgt Srvcs (Sound Health) ✔ HMO Option / HMO Choice ✔ Engineers ✔✗ HMO of Washington ✔ Epoch Group ✔ Hometown Health Partners ✔ Epoch Group, the (Health Infonet) ✔ Humana Care Plan ✔ Equicor ✔ Humana Group Health Plan ✔ Equicor-Ppo ✔ Humana Health Plan ✔ Equitable (Cigna) ✔ Humana Insurance Agency ✔ Escobar Diversified ✔ Humana Insurance Company ✔✗ Ethix N.W. ✔ IAC International ✔✗ Federal Blue Cross ✔ First Health ✔ First Health (Alta Health Strategies) ✔ First Integrated Health ✔ Fischer Broadcasting ✗ Bill Secondary Insurance ✔ Flexible Benefits ✔ Fluke Health Plan ✔ Fortis Standard Information Required: ✔ Foundation Health ✔ Gallagher Bassett ✔ Patient Name ✔ Gallagher Benefit Administrators ✔ ✔ Gen. Conf. of 7th Day Adventists Address ✔ General American Life Ins. Company ✔ Date of Birth ✔ Georgia Power Medical Benefits ✔ Glassworkers Indus. Health & Welfare ✔ Social Security Number ✔ Goodyear Tire & Rubber Company ✔ Government Employees Hospital Association ✔ Responsible Party ✔ Grays Harbor Medical ✔ Great-West Life Assurance Company of Am. ✔ Insurance Company Name ✔✗ Group Health Cooperative ✔ ✔✗ Group Health (Puget Sound) ID Number ✔ Guarantee Trust Life ✔ Group Number ✔ Guardian ✔ Gulf Usa (Blue Shield of Idaho) (XNA or XNB)

SEPTEMBER 2000 17 INSURANCE BILLING (509) 927-6250 • 1-800-433-1583

Requirements of Specific Insurance Companies

✔ IAM Northwest Welfare Fund ✔✗ Medical Service Corp of Eastern Wa ✔ Idaho Forest Industry (Blue Cross If Idaho) (XMH) ✔ Medico Life Insurance ✔✗ Idaho PA ✔ Member Service Administrators ✔ IEC Benefit Administrators Inc. (Sound Health) ✔✗ Memorial Clinic Health ✔ ILWU ✔✗ Merdian Health Care Management ✔ Indian Health (Need Name of Tribe) ✔ Merrill Bostrom Associates (MBA) ✔✗ Inland Electrical Workers (IEW) ✔ Met Elect ✔ Inland Empire Bakers Retirees Trust ✔ Metlife Healthcare Network (Ppo & Hmo) ✔ Inland Health ✔ Metra Health ✔ Insurnation Ins. Admin. (Carnation) (1st Choice) ✔ Metropolitan Life Insurance Company ✔ Int’l Association of Machinist ✔ Mid-America Mutual Life ✔ Int’l Longshoreman & Warehouse ✔ Miller Shingle ✔ Int’l Union of Op Engineers (IUOE) (W. WA 1st Choice) ✔✗ Molina ✔ Intercare Benefits System ✔ Montana Medical Benefits Plan ✔ Intercare Health Plans (Health Infonet) ✔✗ Montana PA ✔ Intermountain Administrators ✔ Montana Retail Store Employers (H&W Trust) ✔ Interplan Corporation ✔ Multiplan (hospital only) ✔ ITT Hartford Insurance ✔ Multiplan Inc. ✔ JC Penney ✔ Multiplan PPO (Health Infonet) ✔ JF Malloy & Associates Inc. ✔ Mutual Assurance Administrators ✔ Jeldwen (Coalition America) ✔ Mutual Group, the ✔ John Alden Employees ✔ Mutual of Omaha Insurance Company ✔ John Alden Intermediate Group ✔ Mutually Preferred ✔ John Alden Life Insurance Company ✔ NW Administrators ✔ John Hancock Health Security Plan ✔ NW Ironworkers (1st Choice) ✔ John Hancock Mutual Life Insurance Company ✔ NW Ironworkers Health & Security (Group F15) ✔ John Hancock Preferred Health Plan ✔ NW Laborers Employers Health ✔ Jones Hill & Mercer Employee Benefits ✔ NW Plumbing & Pipefitting ✔ Kana WHA Benefit Services Inc. ✔ NW Roofers & Employers Health (Group F26) ✔ Kansas City Life Insurance Company ✔ NW Roofers Trust ✔ Key Benefits Administrators ✔ NW Sheetmetal Workers Trust ✔ King Care ✔ NWMB (NW WA Medical Bureau)(Healthy Options) ✔ Kipp & Co. ✔ NASE (National Alliance Self-Employed) ✔ KFHP (Kaiser Foundation Health Plan)(Healhty Opt) ✔ National Association Letter Carriers Affordable ✔ Kirke-Van Orsdel,Inc. ✔ National Automated Sprinkler Industry ✔✗ Kitsap County Medical ✔ National Car Rental ✔ L&H Administrators ✔ National Elevator (PHCS) ✔ L&I (Labor & Industry) L&I claim #, employer, DOI, nature of injury & standard info ✔ National Health Services ✔ Laborers ✔ National Preferred Provider Network ✔ Lamb Weston (only with LWN prefix) ✔ National Rural Letter Carrier Association ✔ LDR Veba Trust ✔ National Rural Electric (NRECA) ✔ Liberty Northwest Companies ✔ Nationalcare Network ✔ Lincoln National Life Insurance Group Trust ✔ Nationwide Group ✔ Lineco ✔ Nationwide Insurance ✔✗ LMSB (Blue Shield of Idaho) (XNA or XNB) ✔ Nationwide Life & Health ✔ Loomis Company ✔ Negotiated Provider Contracts Inc. ✔ MBA of Wyoming ✔ Nelson Trust ✔ MPS (also known as Blue Cross of Montana) ✔ Nestles Company ✔ MS Administration Services ✔ New England, The ✔✗ MSC Classic Care ✔ New York Life Insurance Company ✔ Mailhandlers-CAC ✔ NGS American ✔ Managed Healthcare Northwest ✔ Nippon Life Insurance Company of America ✔ Marriott ✔ North American ✔ Masonry Welfare Trust ✔ North Coast Elect Company ✔ Massachusetts Mutual Life Insurance Company ✔ North Texas Health Care ✔ Masters, Mates, & Pilots ✔ Northern Alaska Carpenters Trust ✔ Medco Value Plus ✔ Northwest Administrators ✔ Medical Control,Inc. ✔ Northwest Airlines ✔ Medical Development International ✔ Northwestern National Life Insurance Company ✔✗ Medical Service Corp. Classic Care ✔ National Rural Letter Carrier Association

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✔ Nylcare Healthy Options ✔ Pro-Net ✔ Nylcare Health Plans (Basic Health Plans) ✔ Pro-Vantage ✔ Olympic Benefits Inc. ✔✗ Providence Preferred ✔ Olympic Health Management Systems ✔ Provident Life & Acc Insurance Company of Am ✔ One Health Plan ✔ Provider Networks of America (Pro-Net) ✔ Operating Engineers Locals 302 & 612 ✔ Prucare (HMO) & (Plus) ✔ Operating Engineers (Eastern WA) ✔ Prudential ✔ Optima ✔ Prunetwork ✔ Options (Group Health) ✔ Public Employees Benefit Board ✔ Options Health Care ✔ Puget Sound Benefit Trust ✔ Options Prime Plan, The ✔ Puget Sound Benefits Trust (Group F25) ✔ Oregon Dental Services (ODS) ✔ Puget Sound Electrical Workers Trust ✔✗ Oregon Medical Assistance Program ✔ Puget Sound Electrical Workers (Group 33) ✔ Oregon Pacific States ✔✗ Qualmed (Eastern WA) (Molina) ✔ Oxford Health Plan ✔ Quigg Brothers Schermer Health & Welfare ✔ Oxford Life ✔✗ Railroad Medicare ✔ P-5 Electronic Health Systems ✔ R.E. Harrington ✔ Pacc Health Plans ✔✗ Reciprocity (Group Health) ✔ Pacific NW Grain & Feed Association ✔✗ Regence ✔ Pacific Grocers Employee Trust ✔ Rehn & Associates ✔ Pacific Health & Life ✔ Reliastar ✔ Pacific Health ✔✗ Retail Clerks Welfare Trust ✔ Pacific Heritage Assurance Company ✔ Risk Management Services ✔ Pacific Heritage Assurance Employee ✔ Rite Aid ✔ Pacific Medical Center ✔ Rodda Paint ✔ Pacific Mutual Life Insurance Company ✔ Ropak ✔ Pacific NW Alaska Health Trust ✔ Safeway Med (non-union employees) ✔ Pacific Feed & Grain Association ✔ Samba (FBI) ✔✗ Pacificare Benefits Administrators ✔ SBP / Providence Healthcare ✔✗ Pacificare Network Mgt. ✔ Seabury & Smith ✔ Painters Trust ✔ Seco Group ✔ Parker Toyota ✔ Select Benefit Administrators ✔ Pebbles ✔ Select Choice ✔ Pegasus Gold Corp ✔ Selectcare Health Plans (Select) ✔ Perscare ✔ Select Providers ✔ PFL ✔ Self Funded Plans ✔ PHCS (Private Healthcare Systems) ✔ Phillips Administrative Service Inc. ✔ Phoenix Group Services ✔✗ Physicians Health Network ✔ Phoenix Home Life ✗ Bill Secondary Insurance ✔ Phoenix Home Life Mutual ✔ Phoenix Mutual ✔✗ Pierce County Medical Standard Information Required: ✔ Pioneer Life ✔ PMG ✔ Patient Name ✔ Pps Managed Care Network ✔ ✔ Preferred One Address ✔✗ Premera Basic Health Plan ✔ Date of Birth ✔✗ Premera (Blue Cross) ✔✗ Premera Health Plus (Start’s w/zeros if short add) ✔ Social Security Number ✔ Primenet (Wenatchee Valley Clinic)(Qualmed, GH, MSC) ✔ Principal (National) (Sound Health) ✔ Responsible Party ✔ Principal Financial Group ✔ Principal Mutual Life Insurance Company ✔ Insurance Company Name ✔ Printing Industries & Paper Products ✔ ✔ Pro America Managed Care,Inc. ID Number ✔ Procare ✔ Group Number ✔ Progressive Insurance Company ✔✗ Pro-Health Alliance

SEPTEMBER 2000 19 INSURANCE BILLING (509) 927-6250 • 1-800-433-1583

Requirements of Specific Insurance Companies

✔✗ Service Center NW ✔ Washington National Insurance Company ✔ Sheffield Olson & Mcqueen ✔✗ Washington State Health Care Authority ✔ Shopko ✔ Wausau Insurance Companies ✔✗ Skagit County Medical ✔ Wausau Pref Health Plans ✔ Sno-Kist ✔ Welfare & Pension Admin Svcs ✔ Sop Pariseau Association ✔ Western Benefits Admin ✔✗ Sound Alternative (Select) ✔ Western Grocers Assurance Trust ✔ Sound Benefit Administrators ✔ Western Grocers Insurance Company ✔ Spokane Airways ✔ Western Mutual ✔✗ Spokane Physicians Hospital Company (SPHCO) ✔ Western Union Corporation ✔ SSI (Disability) ✔ Western Washington Carpenters ✔ Starmark ✔ Weyerhauser Company Plan ✔ St.Mary Medical ✔✗ Whatcom County Medical ✔ State Mutual Life Assurance ✔ Wilbur Ellis Company ✔ Strang Corp. (Tpail) ✔ Willis Corron Admin Svcs Corporation ✔ Student Insurance ✔ Woodsmall Benefit Services ✔ TGB/USA Inc. ✔ World Insurance ✔ Teamsters (All Others) ✔ Wsu Student Med Insurance Plan ✔ Teamsters Local 582 (INBA - Spokane area) ✔✗ Wyoming PA (Title XIX) (starts with 0060) ✔ Teknon Inc. ✔ Yakima Indian Nation Tribal Insurance ✔✗ Thurston County Medical ✔ Zenith Administrators ✔✗ Timber Products Manufacturing Trust ✔ Zosel Lumber Company ✔ Time Insurance ✔ TNT United Truck Lines ✔ Tongass Timber Trust ✔ Tooling & Manufacturing Association ✔ TPA of Washington ✔ Travelers Health Network (Hmo & Care Opts) ✔ Travelers Plan Administrators ✔ Travelers, The ✔ Travelers / CGT-PPO ✔✗ Travelers Medicare (Railroad Medicare) ✔✗ Tricare ✔ Tri-Valley Growers ✔ Trusteed Plan Service Corp. ✔ Trustmark (Benefit Trust Life Insurance Company) ✔ UFCW (National Health & Welfare Fund) ✔ UICI Administrators ✔ Unicare Life & Health Insurance Co ✔ Unicare ✔✗ Uniform Medical (UMP) ✗ Bill Secondary Insurance ✔ Uniform Svcs Family Health Plan ✔ United Chambers Insured Plans ✔ United Employees Benefit Trust Standard Information Required: ✔ United Food & Commercial Workers Trust ✔ United Healthcare ✔ Patient Name ✔ United Medical Resources ✔ ✔✗ United NW Services Inc. (11U or 12U) Address ✔ United of Omaha ✔ Date of Birth ✔ Univar ✔✗ UPREH (Railroad Medicare) ✔ Social Security Number ✔ USA Healthnet ✔ USC ✔ Responsible Party ✔ Vantage A / R&PPO ✔✗ Walla Wall County Medical ✔ Insurance Company Name ✔ Walmart (Use bill class 57 if states 1st choice) ✔ ✔✗ Washington Basic Health ID Number ✔ Washington Benefits ✔ Group Number ✔ Washington Fire Commission Association ✔✗ Washington Physician Service

20 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 PUBLIC ASSISTANCE BILLING

Washington Public Assistance

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1 7

2 3 4

9 5 10 6

22 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 PUBLIC ASSISTANCE BILLING Washington Public Assistance

When you would like us to bill Washington Public Assistance

The Washington PA program takes several forms. To identify the type of coverage a PA patient may have, a copy of the patient’s current Medical Identification Card is neeeded. The cards are issued to Remember, HIC means Medicare! patients monthly with effective dates in the upper right corner.

PA patients not covered under Healthy Options are usually billed Please, ALWAYS attach a current directly to the state. The correct insurance number to use on the copy of the Medical Assistance ID requisition is the Patient Identification Code or PIC number. It Card for that patient to the includes the patient’s initials, date of birth, five letters of the last laboratory requisition. name, and ends with an alpha character in the TB column.

Successful Laboratory Requisitions, WA Public Assistance Billing

When billing Medicaid, the following information is always required on the laboratory requisition:

1. Patient’s full name

2. Patient’s sex

3. Patient’s date of birth

4. Patient’s phone number

5. Responsible party’s name (if not patient)

6. Responsible party’s full address

7. Date and time of collection and fasting status

8. Whom is to be billed (Circle PA)

9. Patient’s Social Security Number

10. Patient’s identification code (PIC)

11. Test ordered checked with proper and valid ICD·9 noted beside

12. Attached copy of current Medical Assistance Card or coupon

SEPTEMBER 2000 23 PUBLIC ASSISTANCE BILLING (509) 927-6250 • 1-800-433-1583

24 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 HEALTHY OPTIONS BILLING

Washington Healthy Options

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2 3 4

5 9

10 11 coupon attached

26 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 HEALTHY OPTIONS BILLING Washington Healthy Options

When you would like us to bill Washington Public Assistance

Healthy Options plans are provided by private insurances who have financial responsibility for all of a patient’s care. Healthy Options Please, ALWAYS attach a current claims are sent directly to the private insurance, not to the state. copy of the Medical Assistance ID Those covered under Healthy Options have a letter abbreviation in Card for that patient to the the HMO column on the Medical Identification Card. With an HMO laboratory requisition. indicator, you must ask to see the patient’s private insurance card to obtain correct and complete billing information. If the referring physician is not the PCP, a referral must be completed by the PCP for laboratory charges to be covered.

Successful Laboratory Requisitions, Healthy Option Billing

When billing Medicaid, the following information is always required on the laboratory requisition:

1. Patient’s full name

2. Patient’s sex

3. Patient’s date of birth

4. Patient’s phone number

5. Responsible party’s name (if not patient) and full address

6. Date and time of collection and fasting status

7. Whom is to be billed (circle PA)

8. Patient’s Social Security Number

9. Healthy Options plan name

10. Insurance identification number

11. Hand-written “Coupon Attached”

12. Test ordered checked with proper and valid ICD·9 noted beside

13. Attached copy of current Medical Assistance Card or coupon SEPTEMBER 2000 27 HEALTHY OPTIONS BILLING (509) 927-6250 • 1-800-433-1583

Sample Medical Assistance ID (MAID) Card With HIC Number

Please read the back of this card. MEDICAL IDENTIFICATION CARD This Card Valid From: 050198 123 Main Street To: 053198 Anytown, WA 98000 HIC marker on a MAID with or without Patient Identification Code (PIC) Medical Coverage Information Initials Birthdate Last Name TB Insurance Medicare HMO Detox Restriction Hospice DD Client Other a Medicare number provided, B- 050432 HACKE A XX HIC 547474514A indicates the patient has Medicare as his or her primary insurance.

QMB - MECIARE ONLY BUDDY HACKETT 123 MAIN STREET ANYTOWN, WA 98000 056 004018227 L0000000001

SHOW TO MEDICAL PROVIDER AT TIME OF EACH SERVICE (NOT TRANSFERABLE) DSHS 13-030 ACES (04/95) SIGNATURE (Not Valid Unless Signed

The table on the facing page shows identification code for the private insurance plan. In the example above, BCCN indicates the patient has Blue Cross of Washington and Alaska Care Net coverage.

Sample Medical Assistance ID (MAID) Healthy Options Card

Please read the back of this card. MEDICAL IDENTIFICATION CARD This Card Valid From: 050198 123 Main Street To: 053198 Anytown, WA 98000 When the HMO column is marked, Patient Identification Code (PIC) Medical Coverage Information Initials Birthdate Last Name TB Insurance Medicare HMO Detox Restriction Hospice DD Client Other please obtain patient’s private G- 050550 JUMP A BCCN insurance information. G- 090990 JUMP A BCCN

QMB - MECIARE ONLY BUDDY HACKETT 123 MAIN STREET ANYTOWN, WA 98000 056 004018227 L0000000001

SHOW TO MEDICAL PROVIDER AT TIME OF EACH SERVICE (NOT TRANSFERABLE) DSHS 13-030 ACES (04/95) SIGNATURE (Not Valid Unless Signed

When a Medical Assistance ID Card indicates HIC underneath the Patient Identification Code (PIC), that patient has Medicare as their primary insurance. The Medical Assistance ID Card may or may not provide the correct Medicare number. Please follow Medicare billing guidelines for these patients.

28 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 HEALTHY OPTIONS BILLING

Healthy Options and Managed Care

When completing laboratory requisitions for Healthy Options patients, please indicate the name and insurance numbers of the private insurance and attach a copy of the patient’s Medical Identi- fication Card to the requisition.

To identify in which managed care plan a client is enrolled, refer to the Health Maintenance Organization (HMO) column of the client’s Medical ID card. The HMO column should contain a Healthy Op- tions identifier or a BHP Plus identifier. Some identifiers for HMO and BHP+ plans are:

IDENTIFIER HEALTHY OPTIONS BHP PLUS

Ante U.S. Healthcare AUSH AUSP

Community Health Plan CHPW CHPP

Clark United Providers CUP CUPP

Group Health Cooperative of Puget Sound / Group Health Northwest GHC GHP

Kaiser Foundation Health Plan of the Northwest KFHP KHPP

King County Medical Blue Shield/RBS RBS RBSP

Northwest Washington Medical Bureau NWMB NWMP

Qual-Med WA Health Plan, Inc. QMD QMDP

Premera Blue Cross PBC PBCP

SEPTEMBER 2000 29 HEALTHY OPTIONS BILLING (509) 927-6250 • 1-800-433-1583

30 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 CODING

Correct Coding

SEPTEMBER 2000 31 CODING (509) 927-6250 • 1-800-433-1583 Correct Coding

Hints for using ICD·9 codes

Top Ten Most Common Invalid ICD·9 Codes

This list is not all-inclusive, but is a guide only.

185.0 Malignant Neoplasm of Prostate. This code does not need the 0. The valid code is 185.

250 Diabetes Mellitus. This diagnosis always needs a fifth digit. Examples: 250.00 NIDDM without mention of complication 250.10 NIDDM with ketoacidosis, but w/o coma

401 Essential Hypertension. This diagnosis always needs a fourth digit. Examples: 414.00 Unspecified type of vessel 414.01 Native coronary artery 414.02 Autologous vein bypass graft 414.05 Unspecified type of bypass graft

414.0 Coronary Atherosclerosis. This diagnosis always needs a fifth digit. Examples: 414.00 Unspecified type of vessel 414.01 Native coronary artery 414.02 Autologous vein bypass graft 414.05 Unspecified type of bypass graft

436.0 Acute But Ill-Defined Cerebrovascular Disease. This is not a valid code. It does not need a 0. The valid code is 436.

462.0 Acute Pharyngitis. This is not a valid code. It does not need a 0. The valid code is 462.

714 Rheumatoid Arthritis and Other Inflammatory Polyarthropathies. This diagnosis always needs a fourth or fifth digit. The codes for RA can be very site-specific. Example: 714.9 Unspecified inflammatory polyarthropy

32 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 CODING

780.3 Convulsions. This is not a valid code. This diagnosis always needs a fifth digit. Other options: 780.31 Febrile convulsions 780.39 Other convulsions

780.7 Malaise and Fatigue. This is not a valid code. This diagnosis always needs a fifth digit. Other options: 780.71 Chronic fatigue syndrome 780.79 Other malaise and fatigue

789.0 Abdominal Pain. This is not a valid code. This diagnosis always needs a fifth digit. Each quadrant of the abdomen has its own code. 789.00 is valid for Unspecified Abdominal Pain.

SEPTEMBER 2000 33 CODING (509) 927-6250 • 1-800-433-1583

ICD·9 Coding Diagnostic Requirements

On January 1, 1998, 4317 of the Balanced Budget Act (BBA) of 1996 amended 1842(p) of the Social Security Act with this paragraph:

“In the case of an item or service defined in paragraph (3), (6), (8), or (9) of subsection 1861 (s) ordered by a physician or practitioner specified in subsection (b) (18) (C), but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner will be required to provide diagnostic information to the entity at the time the service is ordered by the physician or practitioner.”

In the past, physicians ordering services (such as laboratory, diagnostic X-ray, and DME services) were not required by law to provide diagnosis information to the entity billing Medicare. HCFA took the position that the requirements to provide diagnosis information were part of the relationship between suppliers and providers and their physician clientele and that Medicare would not intervene on behalf of either party. With the passing of the BBA, physicians and other practitioners are now required to provide the information at the time a service is ordered. The most accurate way of providing this information is the use of ICD·9·CM coding at the highest level of specificity.

When ordering multiple tests or services, please link the appropriate diagnoses to the tests being ordered for that diagnosis. The requirement to furnish diagnosis information would not be met if the entity billing Medicare is unable to determine which test is being ordered for the different diagnoses supplied.

If a test or service ordered is subject to the limitation of liability pro- visions and could be denied due to lack of medical necessity, Medi- care recommends that the ordering physician indicate that he/she has a signed waiver of liability in the record to protect the billing entity from liability.

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ESRD Claims and Diagnoses

On the HCFA 1500 claim form for the date of service listed, the pro- This applies to Alaska, Arizona, vider should list only the primary diagnosis for which the patient is Colorado, Hawaii, Nevada, North being treated, and not the patient’s overall primary condition. Dakota, Oregon, South Dakota, Example: A patient sees his family physician for a diabetic condi- Washington, and Wyoming. tion (ICD·9·CM 250.00), and the physician is aware that the patient has renal failure (ICD·9·CM 584-586). However, she is not treating the patient for renal failure because the patient is under the care of a nephrologist. The family physician should bill diagnosis 250.00 on the claim service line and list the renal diagnosis, if at all, only in the claim header (Item 21).

The designated Monthly Capitation Payment (MCP) is reimbursed for the treatment of renal failure (584-586) and related conditions. Therefore, the non-MCP physician should not be billing renal failure or related diagnosis as the primary condition unless the non- MCP physician is actually treating the patient for this condition on the date in question.

A specific diagnosis code and signed waiver must accompany the order for a laboratory test that could be denied due to “Medical Necessity.”

■ Absence of a diagnosis code will result in a phone or fax request for one.

■ Absence of a signed waiver will result in no payment if Medicare denies the procedure.

■ Obtain a waiver if test requested is on a Medical Review Policy.

■ Make sure the waiver specifies the test that could be denied, signature of patient, date, and checked box indicating the reason why denial is possible.

■ Provide a diagnosis code by each test ordered.

■ Indicate “Screening” or V70.0 if test is for screening purposes.

SEPTEMBER 2000 35 CODING (509) 927-6250 • 1-800-433-1583

Outpatient Diagnostic Coding & Reporting Guidelines Official outpatient ICD·9·CM guidelines for coding and reporting

The official guidelines should be the basis on which all coding and sequencing decisions are made when the codebooks do not provide specific direction through the use of various conventions and notes. These guidelines were approved for use by hospitals/physicians in coding and reporting hospital-based outpatient services. The terms “visit” and “encounter” are both used to describe outpatient service in the guidelines.

Outpatient Coding Guidelines

12 A Appropriate codes for outpatient reporting. Assign from the range of codes 001.0 through V82.9 to identify the diagnosis, symptom, problem or other reason for the encounter. V codes can be used as the first listed diagnosis as long as the code itself is not prohibitive. For example, code V66.7, encounter for palliative care, is used as a secondary only. See Coding Clinic, 1998 1 Q pp.1142.

12 B For accurate reporting of ICD·9·CM diagnosis codes, the documen- tation should describe the patient’s condition, using terminology that includes specific diagnoses as well as symptoms, problems or reasons for the encounter. This document is approved by the cooperating parties: 12 C The selection of codes 001.0 through 999.9 will frequently be used to describe the reason for the encounter. These codes are from the AHA The American Hospital section of ICD·9·CM for the classification of diseases and injuries. Association

HCFA Health Care Financing 12 D Symptoms and signs permissible. Codes that describe symptoms and Administration signs are acceptable for outpatient reporting purposes, when an NCHS National Center for Health established diagnosis has not been diagnosed (confirmed). For ex- Statistics ample, a patient is admitted with heart palpitations. An EKG is per- AHIMA American Health Information formed without a conclusive diagnosis. Heart palpitation, symptom Management Association code 785.1, is acceptable as the final diagnosis in this case. Chap- ter 16, including codes 780.0-799.9 contains many, but not all of the symptom codes.

36 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 CODING

12 E V codes are provided to deal with occasions when circumstances other than a disease or injury are recorded as diagnosis or problems.

12 F Use three-digit codes only if it is not further subdivided. Where fourth-digit or fifth-digit subclassifications are provided, they must be used.

12 G Additional diagnoses. The first listed diagnosis on the outpatient claim should be for the diagnosis, condition, problem, or other reason for the encounter/visit, documented in the record to be chiefly responsible for the services provided. Additional documented diagnoses are listed secondly. For example, a patient is in the outpatient clinic for chronic urinary tract infection (UTI). Antibiotics are changed to treat the UTI. The physician also documents that the patient has asthma, stable, controlled by inhaler. Assign code 599.0, UTI first, followed by code 493.90 for asthma.

12 H Probable diagnoses. Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule-out” or working diagnosis. Rather, code the condition to the highest degree of certainty. This would include symptoms, signs, abnormal test results, or other reasons. For example, a patient is admitted for chest X-ray. The physician documents lung mass, probable abscess. Assign code 786.6, mass in chest. Had the physician documented “lung mass due to lung abscess,” then code 513.0, abscess of lung, would be assigned. Remember this is contrary to instructional notes of the inpatient guidelines.

12 I Chronic diseases. Any chronic ongoing diseases, which are documented and treated, are reported as many times as a patient receives treatment. If a patient is treated in the outpatient area five different times for insulin dependent diabetes mellitus, then 250.01 may be used as the diagnosis for each encounter.

12 J Other diagnoses. Code all of the documented conditions that coexist at the time of the encounter and require or affect patient care treatment or management. Do not, however, code conditions that were previously treated and no longer exist. History codes (V10 –9) can be used if the historical condition impacts current care. For example,

SEPTEMBER 2000 37 CODING (509) 927-6250 • 1-800-433-1583

a patient presents at the clinic for hematemesis. A family history of stomach carcinoma is documented. The patient has a history of a musculoskeletal disorder and currently has anemia. Appropriate codes for this outpatient visit are 578.0, 285.9 and VI 6.0. The history of musculoskeletal disorder would not be coded, as it has no bearing on this visit.

12 K, L Additional chronic conditions. When patients are receiving diagnostic or therapeutic services only during a visit, list that condition first (except for a patient receiving chemotherapy, radiation therapy or rehabilitation, in which case the V code is assigned). Codes for other diagnoses, such as chronic conditions, may be sequenced as secondary diagnoses. For example, a patient is brought to the bronchial inhaler for asthma. Assign V58 followed by 153.9, 285.9, and 493.90. Many businesses fail to code secondary diagnoses, which may im- pact future ambulatory payment classification (APC) reimburse- ments.

The official outpatient guidelines skip the letter M.

12 N Preoperative evaluations. For patients receiving preoperative evaluations only, sequence a code from category V72.8, other specified examinations, to describe pre-op consultations. For example, a patient, scheduled to have inguinal hernia repair later in the month is seen for a preoperative cardiovascular examination in the outpatient clinic. No problems are identified, other than the inguinal hernia. Code V72.6 I, preoperative cardiovascular examination followed by 550.90 for the inguinal hernia.

12 O Surgery Diagnosis. For ambulatory surgery, code the diagnosis for These are just some of the which the surgery is performed. If the preoperative and postopera- guidelines. We suggest that tive diagnoses are different, code the postoperative diagnosis you review all of them in because it is the most definitive. For example, if a patient is sent depth in the March 2000 for outpatient skin biopsy, and the preoperative diagnosis is “skin edition of Official Outpatient lesion” and the postoperative diagnosis is “solar keratosis,” assign Coding Guidelines by AHIMA. code 702.0 for the solar keratosis.

38 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 CODING

Customized ICD·9 Requisition Policy

Physician and non-physician practitioners are now required (under a key provision of the Balanced Budget Act of 1997) to furnish proof of medical necessity on all ordered items or services when such information is required as a condition of Medicare payment. To facilitate submission of this information, we offer clients customized requisitions containing tests and test-specific ICD·9 diagnostic codes selected by clients.

Individual tests and/or profiles and diagnostic information printed on the custom requisition are determined solely by the ordering physician. We prints only those diagnostic codes (with the accom- panying diagnoses) supplied by the ordering physician. In addition, clients have the opportunity with each test and/or profile to provide an alternative to the diagnostic codes recorded on the requisition by using the “other” option.

At the time of implementation of any customized ICD·9 requisition, and annually thereafter, the physician must, as a condition for cre- ating or continuing the custom ICD·9 requisition, sign a physician acknowledgment form, verifying that the diagnostic information on the customized requisition has been determined solely by the ordering physician. The physician is asked to affirm that:

■ He or she has requested the creation of a customized ICD·9 requisition that includes the tests and/or profiles and respective diagnostic codes listed on the request form.

■ He or she understands that the laboratory is not rendering any legal or other professional services or advice in providing the codes on the customized requisition.

■ He or she represents that the diagnostic information provided with each test and/or profile accurately reflects his/her current knowledge of the emergent nature or severity of the each patient’s complaint or condition, and that this information can be substantiated by each patient’s medical record.

SEPTEMBER 2000 39 CODING (509) 927-6250 • 1-800-433-1583

■ He or she has provided, in each instance, the most specific code for the patient’s current condition. If not specifically listed, he or she will record the necessary code in the space provided on the customized requisition.

Compliance with this policy is reviewed annually to verify that all physician clients who have established customized ICD·9 requisitions have on file a current physician acknowledgment form.

Customized ICD·9 Requisition Request Form

TEST OR PROFILE CPT CODE ICD·9 CODE

PHYSICIAN NAME DATE OF REQUEST

40 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 CODING

Customized ICD·9 Requisition Sample

Contact your local maketing representative for more information.

SEPTEMBER 2000 41 CODING (509) 927-6250 • 1-800-433-1583

Customized ICD·9 Requisition Sample

Contact your local maketing representative for more information.

42 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 MEDICARE BILLING

Medicare Billing

SEPTEMBER 2000 43 MEDICARE BILLING (509) 927-6250 • 1-800-433-1583

1 6 6

2 3 4 7

5 9

11 11 11

Tests highlighted in yellow have LMRPs.

44 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 MEDICARE BILLING Medicare Billing

When you would like us to bill Medicare

Successful Laboratory Requisitions, Medicare Billing

The following Medicare billing requirements will assist you to accurately complete laboratory requisitions. The objective is to minimize recurring phone calls to our valued clients and service center employees. Thank you for your attention to detail.

When billing Medicare, the following information is always required on the laboratory requisition:

1. Patient’s full name

2. Patient’s sex

3. Patient’s date of birth

4. Patient’s phone number

5. Patient’s full address

6. Date and time of collection and fasting status

7. Whom is to be billed (circle Medicare)

8. Patient’s Social Security Number

9. Insurance ID number (Medicare HIC # + prefix or suffix character(s))

10. Test ordered checked with proper and valid ICD·9 noted beside

11. Signed and dated waiver – with test(s) listed and reason(s) specified

12. Attached copy of front of Medicare card

SEPTEMBER 2000 45 MEDICARE BILLING (509) 927-6250 • 1-800-433-1583

Medicare Waivers

Medicare law requires that beneficiaries receive advance notification any time they may be financially liable for services that Medicare may deny as medically unnecessary. This advance notification takes the form of the ‘Medicare Waiver.’

Medicare is very specific on what elements are required on a Medi- care Waiver for that waiver to be considered valid. Absence of any of the four required elements invalidates that waiver and is the same as no waiver at all.

Please provide an ICD·9 code Please take a moment to review the requisition example. The fol- next to each test ordered for lowing must be completed on each Medicare Waiver obtained: Medicare patients. 1. Patient must sign the waiver.

2. Patient must date the waiver.

3. Specific tests the patient was advised could be denied must be noted.

4. The reason these tests may be denied must be noted (check applicable box).

The procedure for obtaining a Medicare Waiver is based on the current list of tests for which Medicare requires an ICD·9 code to con- sider payment. Please refer to the “Current Lab Services That Re- quire Proof of Medical Necessity” list. We do not obtain a Medicare Waiver for every Medicare patient.

46 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 MEDICARE BILLING

Advance Beneficiary Notice

The Omnibus Budget Reconciliation Act of 1986 (OBRA) included a limitation of liability (or waiver of liability) provision that provides beneficiaries with protection from liability when they, in good faith, receive services from a Medicare provider for which Medicare payment is subsequently denied as not “reasonable and necessary.”

An Advance Beneficiary Notice (ABN) should be obtained whenever a provider has reason to believe a procedure could be denied as not reasonable and necessary. Generally, services necessitating a signed waiver are those that are payable in some instances, but not payable in others. These can include:

■ Laboratory tests for which the Medicare carrier has established a Local Medical Review Policy.

■ Laboratory tests that are not yet FDA-approved.

■ Laboratory tests that are specifically excluded by the Medicare program. (e.g., General Health Panels, Cross-Linked N-Telopeptides)

■ Routine or Screening Services. As a courtesy, please inform your patient that these services are not covered by Medicare.

Please provide the laboratory with an Advance Beneficiary Notice when you have reason to believe Medicare may deny a procedure as ‘medically unnecessary.’

Ensure that the ABN includes the patient’s signature, date, procedure(s) that could be denied, and the reason for denial.

SEPTEMBER 2000 47 MEDICARE BILLING (509) 927-6250 • 1-800-433-1583

Advance Beneficiary Notice Sample

PATIENT: Your physician has ordered specific tests that he or she has determined to be necessary for your care. Our laboratory will perform these tests and then bill Medicare for these services. Medi- care, however, will pay for only the services that it determines to be “reasonable and necessary” under section 1862(a)(1) of the Medi- care Law. If Medicare determines that a particular service, although it would otherwise be covered, is “not reasonable and necessary” under Medicare program standards, Medicare will deny payment for that service or test. In cases where Medicare denies coverage, the billing will be forwarded to you, and you will be responsible for payment.

We believe that in your case, Medicare is likely to deny coverage of the following test(s):

for the following reason(s):

Medicare may not pay for this service for the provided diagnosis.

Medicare does not pay for tests that do not have FDA approval.

Medicare usually does not pay for routine exams or laboratory screening procedures.

Beneficiary Agreement

(See Advance Beneficiary Notice Above.) I have been notified by my provider that it believes that in my case Medicare is likely to deny payment for the services identified above for the reason(s) stated. If Medicare denies payment, I agree to be personally and fully responsible for payment.

X Date

BENEFICIARY SIGNATURE

48 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 MEDICARE BILLING

Medicare Secondary Payer

Medicare Secondary Payer (MSP) refers to those instances in which Medicare does not have the primary responsibility for paying the medical expenses for a Medicare beneficiary.

All providers and practitioners should screen Medicare patients to obtain correct health insurance information before submitting a primary claim to Medicare. Listed below are some questions that you can ask your patients during your confidential screening that will help you recognize circumstances where Medicare may be the secondary payer:

■ Are you currently employed?

■ Is your spouse currently employed?

■ Are you covered under an employer or union health plan that should be primary to Medicare?

■ Did you sustain an injury/illness while at work?

■ Are your injuries accident-related?

By using the above questions to initially screen your Medicare patients, you will help reduce costs to the Medicare Program as well as administrative costs to your practice.

Requisitions provided to the laboratory should reflect accurate patient insurance information, including screening for Medicare Sec- ondary Payer. Laboratory Patient Service Center employees will provide Medicare Secondary Payer screening when performing phle- botomy on Medicare beneficiaries. Physician offices that are unable to provide Medicare Secondary Payer screening are encouraged to direct their patients to our Patient Service Centers for this vital requirement of the Medicare Program.

References Medicare Part B 1999 Basic Billing Manual. Medicare B New, Issue 167 “Medicare Secondary Payer” www.noridian.com/medweb

SEPTEMBER 2000 49 MEDICARE BILLING (509) 927-6250 • 1-800-433-1583

Medicare Secondary Payer Questions

PATIENT NAME LAST FIRST

DATE OF SERVICE MEDICARE NUMBER

❑ YES ❑ NO 1. Are you currently employed?

If YES, do you have group health plan coverage through your employment?

If YES, please provide insurance information.

❑ YES ❑ NO 2. Is your spouse currently employed?

If YES, are you covered under your spouse’s employment group health plan?

If YES, please provide insurance information.

❑ YES ❑ NO 3. Are you covered under an employer or union health plan that should be primary over Medicare?

If YES, please provide insurance information.

❑ YES ❑ NO 4. Are these services related to an injury or illness occurring at work?

❑ YES ❑ NO 5. Are these services related to injury sustained in an accident?

❑ YES ❑ NO 6. Are you entitled to benefits payable under the Federal Black Lung Program, Veterans Administration, or End-Stage Renal Disease programs?

SIGNATURE OF CUSTOMER SERVICE REPRESENTATIVE

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Tests Requiring Proof of Medical Necessity IDAHO Medicare B

Applies to: “We have reason to believe Medicare may deny payments for these AML Alpha Medical Laboratory services” ALWAYS inform the patient of non-coverage and obtain a TVL Treasure Valley Laboratory signed Advance Beneficiary Notice.

* Idaho Medicare Part B Carrier policies apply only to services physi- cally performed in the state of Idaho at our Alpha or Treasure Valley patient service centers. All other laboratory testing is performed in Washington and is subject to the Part B Carrier Listing.

WORKPAR DESCRIPTION CPT4 EFF DATE WORKPAR DESCRIPTION CPT4 EFF DATE ADH Agrinine Vasopressin Hormone 84588 Investigational LEISAB Leishmania Antibody Panel 86717 Investigational AFP Alpha-Feto Protein 82105 5/15/97 L PHENO Lipid Phenotyping 83715 3/15/97 ANTI-MYO Anti-Myocardial AB 86256 Investigational LIPID Lipid Profile 80061 3/1/97 BSS Beta Strep Culture 87081 12/20/97 MAG Magnesium 83735 3/1/97 C2 C2 Complement Component 86160 Investigational MBP Myelin Basic Protein 83873 Investigational CA27.29 CA 27.29 86316 5/15/97 B.NTX NTX 82523 Not Covered CA125 CA125 86316 5/15/97 OSTEO Osteocalcin 83937 Investigational CA19-9 CA19-9 86316 Investigational PTT Partial Thromboplastin Time 85730 6/15/98 CA72-4 CA72-4 86316 Investigational B19PAN Parvovirus Evaluation Multiple Investigational CBC, CBCW, CBCMAN CBC (All complete Blood Counts) 85022-85031 2/1/97 PLT Platelet Counts 85585,85590,85595 6/15/98 CEA CEA 82378 5/15/97 POLYMY Polymyositis AB 86331 Investigational PAP SMEARS Cervical Smears 88150-88157 12/10/97 PT or PT.A * Pro Time 85610 9/16/96 CHO Cholesterol 82465 3/15/97 PAP Prostatic Acid Phosphatase 84066 12/10/97 UA.ID Culture ID by Commercial Kit 87088 12/10/97 PSA PSA 84153 08/1/96 CULT.CC Culture Urine Colony Count 87086-87087 12/10/97 RA RA Titer 86430-86431 3/1/97 DIF Differential (Blood Counts), Manual 85007-85009 2/1/97 RTC Reticulocyte Counts 85044-85045 6/25/98 DIG Digoxin 80162 6/15/98 RPR RPR 86592 1/1/98 DLDL Direct LDL 83721 3/15/97 SED Sedimentation Rate 85651-85652 3/15/99 ECHINO Echinococcus AB, IGG 86682 Investigational T3UP T3 Uptake 84479 3/15/97 FERR Ferritin 82728 3/15/97 T4 T4 84436 3/15/97 FIBRON Fibronectin Aggregates, IgA Multiple Investigational BTB Thryoid Profile 84479, 84436 3/15/97 FPSA Free PSA 84154 Investigational THYRO Thyroglobulin 84432 Investigational FREE T4 Free T4 84439 3/15/97 TGNICH Thyroglobulin & Anti-Thyroglobulin AB Multiple Investigational FTA.ARUP FTA Confirmation (Treponema Pallidum) 86781 1/1/98 TRANSFERRIN Transferrin 84466 3/15/97 GGT Gamma Glutamyltransferase 82977 6/1/98 TRIG Triglyceride 84478 3/15/97 GLU Glucose 82947-82948, 82962 12/10/97 TSH TSH 84443 3/15/97 GLHGB Glycohemoglobin 83036 3/15/96 UA.MICRO Urinalyisis, Microscopic Only 81015 8/1/99 HCG HCG Qualitative 84703 5/15/97 UA Urinalysis 81002, 81003 8/1/99 HCG-QUANT HCG Quantitative 84702 5/15/97 UAM Urinalysis Dip Stick, with Micro 81000,81001 8/1/99 HCVBDNA HCV bDNA 87522 Investigational DPS Urinalysis, Dip Stick 81002, 81003 8/1/99 HDL HDL 83718 3/1/97 81005, 81007 8/1/99 HCT Hematocrit (Including Spun) 85013-85014 2/1/97 VDRL, TPPA VDRL (Syphilis, Quant) 86593 10/1/98 HGB Hemoglobin 85018 2/1/97 VIT D Vitamin D (1,25-Dihydroxy) 82652 Investigational AUT Hemogram, Automated 85021, 85027 3/15/97 HCVGAR Hepatitis C Genotyping by PCR & Sequencing Multiple Investigational HCVPAR Hepatitis C RNA, Qual by PCR 87521 Investigational HEPCQT Hepatitis C RNA, Quant by RTPCR 87522 Investigational HIST-U Histamine, Urine Random 83088 Investigational HIST Histamine, Whole Blood 83088 Investigational HIVBDNA HIV bDNA 87536 Investigational HTLVWB HTLV AB I/II, WB Serum 86689 Investigational HYPOA Hypothyroid Profile 84479, 84436, 84443 3/15/97 CAL-ION Ionized Calcium 82330 3/15/97 IRON.BIND Iron Binding Capacity 83550 3/15/97 IRN Iron, Total 83540 3/15/97 LEGION Legionella Culture 87081 12/20/97

SEPTEMBER 2000 51 MEDICARE BILLING (509) 927-6250 • 1-800-433-1583

Tests Requiring Proof of Medical Necessity WA Medicare A1

Applies to: The Fiscal Intermediary has published Local Medical Review Poli- CENT Providence Centralia cies on the following procedures. Review the diagnosis and obtain SHMC Sacred Heart Medical Center a Notice of Noncoverage when not payable.

WORKPAR DESCRIPTION CPT4 EFF DATE ADH Agrinine Vasopressin Hormone 84588 Investigational ANTI-MYO Anti-Myocardial AB 86256 Investigational C2 C2 Complement Component 86160 Investigational CA19-9 CA 19-9 86316 Investigational CA72.4 CA 72-4 86316 Investigational CERVICAL SMEARS Cervical Smears 88150-88164 1996 CBC,CBCMAN,CBCW Complete Blood Counts 85022-85031 2/1/00 UA.ID Culture ID by Commercial Kit 87088 12/29/97 CULT.CC Culture, Urine 87086-87087 12/29/97 DIF Differential, Manual 85007 2/1/00 ECHINO Echinococcus AB, IGG 86682 Investigational FIBRON Fibronectin Aggregates, IgA Multiple Investigational FTA.ARUP FTA Confirmation Test 86781 12/29/97 GGT GGT 82977 12/29/97 HCVBDNA HCV bDNA 87522 Investigational HCVGAR HCV Genotyping by PCR & Sequencing Multiple Investigational HCVPAR Hepatitis C RNA, Qual by PCR 87521 Investigational HCT Hematocrit 85013-85014 2/1/00 HGB Hemoglobin 85018 2/1/00 AUT Hemogram (Blood Count) 85021, 85027 2/1/00 HEPCQT Hepatitis C RNA, Quant by RTPCR 87522 Investigational HIST-U Histamine, Urine Random 83088 Investigational HIST Histamine, Whole Blood 83088 Investigational HIVBDNA HIV bDNA 87536 Investigational HTLVWB HTLV AB I/II, WB Serum 86689 Investigational LEISAB Leishmania Antibody Panel 86717 Investigational MBP Myelin Basic Protein 83873 Investigational OSTEO Osteocalcin 83937 Investigational PTT Partial Thromboplastin Time 85730 12/29/97 B19PAN Parvovirus Evaluation Multiple Investigational PLT Platelet Count Auto 85595 12/29/97 PLATELET MAN Platelet Count Manual 85590 12/29/97 PLATELET EST Platelet Estimate 85585 12/29/97 POLYMY Polymyositis AB 86331 Investigational PT Pro Time 85610 12/29/97 PAP Prostatic Acid Phos 84066 12/29/97 PSA Prostatic Specific Antigen 84153 1996 FPSA PSA, Free Multiple Investigational RTC Reticulocyte Counts 85044-85045 12/29/97 RA Rheumatoid Factor Test 86430-86431 12/29/97 RPR RPR 86592-86593 12/29/97 THYRO Thyroglobulin 84432 Investigational TGNICH Thyroglobulin & Anti-Thyroglobulin AB Multiple Investigational VDRL VDRL (Syphilis, Quant) 86593 12/29/97 VIT D Vitamin D (1,25-Dihydroxy) 82652 Investigational WBC White Blood Cell Count 85048 9/1/95

52 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 MEDICARE BILLING

Tests Requiring Proof of Medical Necessity WA Medicare A2

Applies to: The Fiscal Intermediary has published Local Medical Review Poli- SJT St. Joseph cies on the following procedures. Review the diagnosis and obtain STC St. ClaIre a Notice of Noncoverage when not payable. STF St. Francis PGMC PGMC / PHC

WORKPAR DESCRIPTION CPT4 EFF DATE ADH Agrinine Vasopressin Hormone 84588 Investigational Anti-Myo Anti-Myocardial AB 86256 Investigational C2 C2 Complement Component 86160 Investigational CA19-9 CA 19-9 86316 Investigational CA72.4 CA 72-4 86316 Investigational Cervical Smears Cervical Smears 88150-88164 1996 CBC,CBCMAN,CBCW Complete Blood Counts 85022-85031 2/1/00 UA.ID Culture ID by Commercial Kit 87088 12/29/97 CULT.CC Culture, Urine 87086-87087 12/29/97 DIF Differential, Manual 85007 9/1/95 ECHINO Echinococcus AB, IGG 86682 Investigational FIBRON Fibronectin Aggregates, IgA Multiple Investigational FK506 (PGMC only) FK506 80197 Investigational FPSA Free PSA 84154 Investigational FTA.ARUP FTA Confirmation Test 86781 12/29/97 GGT GGT 82977 12/29/97 HCVGAR (PMC only) HCV Genotyping by PCR & Sequencing Multiple Investigational HCT Hematocrit 85013-85014 9/1/95 HGB Hemoglobin 85018 9/1/95 AUT Hemogram (Blood Count) 85021, 85027 9/1/95 HIST-U Histamine, Urine Random 83088 Investigational HIST Histamine, Whole Blood 83088 Investigational HTLVWB HTLV AB I/II, WB Serum 86689 Investigational LEISAB Leishmania Antibody Panel 86717 Investigational MBP Myelin Basic Protein 83873 Investigational OSTEO Osteocalcin 83937 Investigational PTT Partial Thromboplastin Time 85730 12/29/97 B19PAN Parvovirus Evaluation Multiple Investigational PLT Platelet Count Auto 85595 12/29/97 Platelet Man Platelet Count Manual 85590 12/29/97 Platelet Est Platelet Estimate 85585 12/29/97 POLYMY Polymyositis AB 86331 Investigational PT Pro Time 85610 12/29/97 PAP Prostatic Acid Phos 84066 12/29/97 PSA Prostatic Specific Antigen 84153 1996 RTC Reticulocyte Counts 85044-85045 12/29/97 RA Rheumatoid Factor Test 86430-86431 12/29/97 RPR RPR 86592-86593 12/29/97 THYRO Thyroglobulin 84432 Investigational TGNICH Thyroglobulin & Anti-Thyroglobulin AB Multiple Investigational VDRL VDRL (Syphilis, Quant) 86593 12/29/97 VIT D Vitamin D (1,25-Dihydroxy) 82652 Investigational WBC White Blood Cell Count 85048 9/1/95

SEPTEMBER 2000 53 MEDICARE BILLING (509) 927-6250 • 1-800-433-1583

Tests Requiring Proof of Medical Necessity WA Medicare B

Applies to: “We have reason to believe Medicare may deny payments for these PAML Pathology Associates services” ALWAYS inform the patient of non-coverage and obtain a Medical Laboratories signed Advance Beneficiary Notice. TCL Tri-Cities Laboratory OML Olympia Medical Laboratory

WORKPAR DESCRIPTION CPT4 EFF DATE WORKPAR DESCRIPTION CPT4 EFF DATE ADH Agrinine Vasopressin Hormone 84588 Investigational HIV-1, Direct Probe 87534 7/1/99 AFP Alpha Fetoprotein 82105 1996 HIV-1, Quant 87536 7/1/99 ANTI-MYO Anti-Myocardial AB 86256 Investigational HIV1US HIV-1, Ultrasensitive Quant by PCR 87536 7/1/99 C2 C2 Complement Component 86160 Investigational HIV-2, Amplified Probe 87538 7/1/99 CA125 CA125 86316 1996 HIV-2, Direct Probe 87537 7/1/99 CA15-3 CA15-3 86316 1996 HIV-2, Quant 87539 7/1/99 CA19-9 CA19-9 86316 Investigational HTLVWB HTLV AB I/II, WB Serum 86689 Investigational CA27.29 CA27-29 86316 1996 HYPOA Hypothyroid Profile Multiple 12/10/96 CA72-4 CA72-4 86316 Investigational IRON.BIND Iron Binding Capacity 83550 10/10/96 CBC, CBCW, CBCMAN CBC (All complete Blood Counts) 85023-85025 1996 IRN Iron, Total 83540 10/10/96 CEA CEA 82378 1996 LEISAB Leishmania Antibody Panel 86717 Investigational PAP SMEARS Cervical Smears 88150 1996 L PHENO Lipid Phenotyping 83715 12/10/96 CHO Cholesterol 82465 12/10/96 LIPID Lipid Profile 80061 12/10/96 UA.ID Culture ID by Commercial Kit 87088 5/1/98 MAG Magnesium 83735 10/10/96 CULT.CC Culture Urine Colony Count 87086-87087 5/1/98 MBP Myelin Basic Protein 83873 Investigational Multiple Cytogenetics Studies, All 88230-88299 4/1/99 NTX N-Telopeptides 82523 2/1/100 DIF Differential (Blood Counts), Manual 85007 7/1/96 B.NTX NTX 82523 2/1/100 DLDL Direct LDL 83721 12/10/96 OC.BLD Occult Blood 82270 1996 ECHINO Echinococcus AB, IGG 86682 Investigational OSTEO Osteocalcin 83937 Investigational FERR Ferritin 82728 10/10/96 PTT Partial Thromboplastin Time 85730 5/1/98 FIBRON Fibronectin Aggregates, IGA Multiple Investigational B19PAN Parvovirus Evaluation Multiple Investigational Multiple Flow Cytometry 88180, 88182 4/10/97 POLYMY Polymyositis AB 86331 Investigational FPSA Free PSA 84153 Investigational POT Potassium 84132 4/10/97 FREE T4 Free T4 84439 12/10/96 PAP Prostatic Acid Phosphatase 84066 5/1/98 FRUCT Fructosamine 82985 12/10/96 PT Prothrombin Time 85610 5/1/98 FTA.ARUP FTA Confirmation (Treponema Pallidum) 86781 5/1/98 PSA PSA 84153 1996 GGT Gamma Glutamyltransferase 82977 5/1/98 RA RA Titer 86430-86431 12/10/96 GLU Glucose 82947-82948 1996 RTC Retic Count 85044-85045 5/1/98 GLYCOALBUMIN Glycoalbumin 82985 12/10/96 RPR RPR 86592-86593 1996 GLHGB Glycohemoglobin 83036 12/10/96 SED Sedimentation Rate 85651-85652 12/15/98 HCG HCG Qualitative 84703 1996 T3UP T3 Uptake 84479 12/10/96 HCG-QUANT HCG Quantitative 84702 1996 T4 T4 84436 12/10/96 HCVBDNA HCV bDNA 87522 Investigational THYRO Thyroglobulin 84432 Investigational HCVGAR HCV Genotyping by PCR & Sequencing Multiple Investigational TGNICH Thyroglobulin & Thyroglobulin Antibody Multiple Investigational HDL HDL 83718 12/10/96 BTB Thyroid Profile 84479, 84436 12/10/96 HCT Hematocrit (Including Spun) 85013-85014 1995 TRANSFERRIN Transferrin 84466 10/10/96 HGB Hemoglobin 85018 1995 TRIG Triglycerides 84478 12/10/96 AUT Hemogram, Automated 85021, 85027 1995 TROPONIN Troponin 84484, 84512 8/1/98 HCVPAR Hepatitis C RNA, Qual by PCR 87521 Investigational TSH TSH 84443 12/10/96 HEPCQT Hepatitis C RNA, Quant by RTPCR 87522 Investigational UAM Urinalysis Dip Stick, with Micro 81000, 81001 1995 HIST-U Histamine, Urine Random 83088 Investigational DPS Urinalysis, Dip Stick 81002, 81003 1995 HIST Histamine, Whole Blood 83088 Investigational UA.MICRO Urinalysis, Microscopic Only 81015 1996 HIV12 HIV (Viral Serology) 86703 1996 VDRL, TPPA VDRL (Syphilis, Quant) 86593 5/1/98 HIVBDNA HIV bDNA 87536 Investigational VIT D Vitamin D (1,25-Dihydroxy) 82652 Investigational HIV.DNA.PCR HIV DNA PCR 87535 7/1/99 WBC White Cell Count 85048 1996 HIVQRP HIV RNA Quantitation by PCR 87536 7/1/99

54 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs IDAHO

LMRPs Idaho Medicare

SEPTEMBER 2000 55 LMRPs IDAHO (509) 927-6250 • 1-800-433-1583 LMRPs – Idaho Medicare

Warranty and Liability Disclaimer

To the best of our knowledge, the code/text diagnosis provided herein has been approved and distributed by the local Medical Review Boards of Washington State (Premera/Blue Cross for Part A and Noridian for Part B) and Idaho State (Cigna for Part B) in compliance with Medicare’s medical necessity regulations regarding laboratory reimbursement. Because we obtain this information from others, we cannot be responsible for its accuracy; however, the information is believed to be current as of the date printed.

Current information can also be found at This information is provided “as is,” without warranty of any www.cignamedicare.com kind, and we expressly disclaim, and the user expressly waives, all guarantees and warranties, duties, and obligations implied in law, including warranties of merchantability and fitness for a particular purpose. In no event shall we be liable for any loss or profit or any other commercial damage, including but not limited to special, incidental, consequential, punitive or other damages.

Please note that this information is also available directly from carriers/fiscal intermediaries in their bulletins or on their websites. Ordering providers are required to provide the most appropriate code/text diagnosis for laboratory tests they order, but are not limited to these codes.

56 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs IDAHO

BACTERIAL CULTURE 238.4-238.7 Polycythemia vera and other hemopoietic disease 245.0 Acute thyroiditis Idaho Medicare Part B/Local Medical Review Policy 261 Nutritional marasmus Medicare Bulletin id 97-008/December 1997 262 Other severe, protein-calorie malnutrition 263.0-263.9 Nutritional deficiencies CPT: 87081 280.0-285.9 Anemias CPT: 87082 287.0-287.9 Purpura CPT: 87083 320.0-326. Inflammatory diseases of the central nervous system CPT: 87084 390-392.9 Acute rheumatic fever CPT: 87085 446.0 Polyarteritis nodosa 460-466.1 Acute respiratory infections There is no published list. Per the December 1997 Bulletin, it states that to print the “ICD9 codes that 480.0-487.8 Pneumonia and influenza would support the need for a bacterial culture is too extensive to be practical”. It states a reasonable 533.00-535.61 Peptic ulcer, gastritis duodenitis ICD9 diagnosis code must be linked with the procedure code. 537.82-537.83 Angiodysplasia of the stomach 555.0-558.9 Regional enteritis, ulcerative colitis, vascular insufficiency of intestine, Reasons for Denial: Screening tests, in the absence of associated signs, symptoms or complaints are gastroenteritis and colitis (radiation, toxic) denied under 1862(a)(7) 562.00-562.13 Diverticulosis and diverticulitis of small and large intestine 566 Abscess of anal and rectal regions Coding Guidelines:Any claim for a test listed in “HCPCS CODES” above must be submitted with an 567.0-567.9 Peritonitis ICD-9 diagnosis code or comparable narrative. 569.82-569.85 Ulceration, perforation, angiodysplasia of intestine 574.00-575.4 Cholelithiasis, cholecystitis ICD-9 code V82.9 (special screening of other conditions, unspecified condition) or comparable narra- 576.1 Cholangitis tives should be used to indicate screening tests performed in the absence of a specific sign, symp- 577.0 Acute pancreatitis tom, or complaint. Use of ICD-9 code V82.9 or comparable will result in the denial od claims as non- 578.0-578.9 GI hemorrhage, including hematemesis and melena covered screening services. 590.0-590.81 Infection of kidney 593.81 Vascular disorders of kidney (hemorrhage, thrombosis) All ICD-9 diagnosis codes must be coded to the highest level of specificity. 599.7 Hematuria 601.2 Abscess of prostate BACTERIAL CULTURE, URINE 602.1 Hemorrhage of the prostate 604.0-604.91 Orchitis, epididymitis Idaho Medicare Part B/Local Medical Review Policy 608.0 Seminal vesiculitis (abscess) (cellulitis) Medicare Bulletin ID 97-009 Effective December 20, 1997 608.4 Other inflammatory diseases of the male genital organs 608.83 Vascular disorders of the male genital organs CPT: 87086 Culture, bacterial, urine; quantitative, colony count 611.0 Inflammatory disease of the breast (abscess) CPT: 87087 …commercial kit 614.0-616.0 Inflammatory disease of the ovary, tubes, pelvis, peritoneum (female) CPT: 87088 …identification, in addition to quantitative or commercial kit 616.3-616.4 Bartholin abscess, other abscesses of vulva 626.0-627.1 Disorders of menstruation; other abnormal bleeding from the female genital tract 038.0-038.9 Septicemia 633.0-633.9 Ectopic pregnancy 580.0-589.9 Nephritis, nephrotic syndrome, and nephrosis 634.00-634.02 Spontaneous abortion with infection, hemorrhage shock 590.0-599.9 Other diseases of urinary system 634.10-634.12 Spontaneous abortion with infection, hemorrhage shock 600-608.9 Diseases of male genital organs 634.50-634.52 Spontaneous abortion with infection, hemorrhage shock 780.6 Fever 635.00-635.02 Legal induced abortion with infection, hemorrhage shock 788.0-788.9 Symptoms involving urinary system 635.10-635.12 Legal induced abortion with infection, hemorrhage shock 790.7 Bacteremia 635.50-635.52 Legal induced abortion with infection, hemorrhage shock 791.0 Proteinuria 637.00-637.01 Unspecified abortion with infection, hemorrhage, shock 791.7 Other cells and casts in urine 637.10-637.12 Unspecified abortion with infection, hemorrhage, shock V72.84 Pre-operative examination, unspecified 637.50-637.52 Unspecified abortion with infection, hemorrhage, shock 638.00-638.01 Failed attempted abortion with infection, hemorrhage, shock BLOOD COUNTS 638.10-638.12 Failed attempted abortion with infection, hemorrhage, shock 638.50-638.52 Failed attempted abortion with infection, hemorrhage, shock Idaho Medicare Part B/ Local Medical Review Policy 639.0-639.1 Complications following abortion, ectopic and molar pregnancies Medicare Bulletin GR 97-1, Jan-Feb 1997 639.5 Shock Following Abortion Or Ectopic And Molar Pregnancies 640.00-640.93 Hemorrhage in early pregnancy CPT: 85007-85031 641.00-641.93 Antepartum hemorrhage 647.00-647.94 Infections complicating pregnancy 001.0-136.9 Infectious and parasitic diseases 648.20-648.24 Anemia in pregnancy 137.00-139.8 Late effects of infectious and parasitic diseases 658.4 Infection of amniotic cavity 150.0-159.9 Malignant neoplasms, gastro-intestinal 666.00-667.14 Postpartum hemorrhage, coagulation defects and retained portion of placenta or 162.2-163.9 Malignant neoplasms, lung, pleura, bronchus membranes 172.0-172.9 Malignant melanoma 669.10-669.4 Shock during or following labor and delivery 174.0-176.9 Malignant neoplasms, breast 670.00-670.44 Major puerperal infections 179 Malignant neoplasm of uterus, part unspecified 672.00-672.04 Pyrexia of unknown origin during puerperium 180.0-189.9 Malignant neoplasms, genitourinary 675.00-675.04 Infection of breasts associated with childbirth 200.0-208.9 Malignant neoplasms, lymphatic and hematopoietic including leukemias 675.80-675.94 Other Specified Infections Of The Breast And Nipple Associated With Childbirth, 233.0-233.9 Carcinoma in situ, breast, genito-urinary Unspecified As To Episode Of Care 235.2-235.5 Neoplasm of uncertain behavior, gastro-intestinal 680.0-680.9 Skin infections 236.0-236.99 Neoplasm of uncertain behavior, genito-urinary 681.00-682.9 Cellulitis and abscess

SEPTEMBER 2000 57 LMRPs IDAHO (509) 927-6250 • 1-800-433-1583

683-686.9 Skin infections 780.4 Dizziness and giddiness 710.0-710.9 Diffuse abscess of connective tissue 783.2 Abnormal loss of weight 711.10-711.49 Arthropathy associated with infection 783.5 Polydipsia 713.2 Arthropathy associated with hematological disorders 788.41-788.43 Frequency of urination and polyuria 714.0-714.49 Rheumatoid arthritis and other inflammatory arthropathies 780.2 Abnormal glucose tolerance test 719.4 Pain in joint 790.6 Other abnormal blood chemistry 720.0-720.9 Ankylosing spondylitis and other inflammatory spondylopathies 791.5 Glycosuria 730.00-730.09 Osteomyelitis 730.10-730.19 Chronic Osteomyelitis, Site Unspecified 730.20-730.29 Unspecified Osteomyelitis, Site Unspecified CALCIUM – IONIZED 759.0 Anomalies of spleen Idaho Medicare Part B/Local Medical Review Policy 780.6 Pyrexia of unknown origin Medicare Bulletin GR 97-1, Jan-Mar 1997 780.79 Malaise and fatigue 782.61 Pallor CPT: 82330 Calcium, ionized 782.7 Spontaneous ecchymoses (purpura) 790.0 Abnormality of red cells 252.0 Hyperparathyroidism 792.1 Non-specific abnormal findings in stool (occult blood) 252.1 Hypoparathyroidism 860.0-869.1 Internal injury thorax, abdomen, pelvis 252.8 Other specified disorders of parathyroid gland 900.00-901.9 Injury to blood vessels of head and neck, and thorax 252.9 Unspecified disorder of parathyroid gland 995.2 Unspecified adverse effect of drug, medicinal or biological substance 259.3 Ectopic hormone secretion, not elsewhere classified, (hyperparathyroidism) 996.60-996.69 Infection due to internal prosthetic device, implant and graft 268.0 Rickets, active V12.3 Personal history of disease of the blood and blood-forming organism 268.1 Ricketss, late effect V58.0 Radiotherapy 268.2 Osteomalacia, unspecified V58.1 Chemotherapy 268.9 Unspecified Vitamin D deficiency V58.61 Long term (current) use of anticoagulants 275.4 Disorders of calcium metabolism, (hypo-, hyper-, pseudo-, parathyroidism) V58.69 Long term (current) use of high risk medications 276.2 Acidosis V67.0-V67.2 Follow-up surgery, radiotherapy or chemotherapy 276.3 Alkalosis V67.51 Follow-up of high risk medication, not elsewhere classified 276.4 Mixed acid-base balance disorder V72.81-V72.83 Other specified examinations, pre-operative cardiovascular, respiratory, other 276.5 Volume depletion specified pre-operative examination 276.6 Fluid overload 276.9 Electrolyte and fluid disorders not elsewhere classified BLOOD GLUCOSE TESTING 278.4 Hypervitaminosis D 571.5 Cirrhosis of liver without mention of alcohol Idaho Medicare Part B/Local Medical Review Policy 571.6 Biliary cirrhosis Medicare Bulletin ID 97-011/Effective December 1997 579.0-579.4 Intestinal malabsorption 579.8-579.9 Other specified and unspecified intestinal malabsorption CPT: 84947 Glucose, quantitative 585 Chronic renal failure CPT: 82948 …blood, reagent strip 586 Renal failure, unspecified CPT: 82962 …blood by glucose monitoring device(s) cleared by the FDA 587 Renal sclerosis, unspecified specifically for home use 588.0 Renal osteodystrophy 588.8 Other specified disorders resulting from impaired renal function V72.84 Preoperative examination, unspecified 588.9 Unspecified disorder resulting from impaired renal function 157.4 Malignant neoplasm of Islets of Langerhans 733.00 Osteoporosis, unspecified 211.7 Benign neoplasm of Islets of Langerhans 775.4 Neonatal hypoparathyroidism 250.00-250.93 Diabetes mellitus 775.7 Late metabolic acidosis of newborn 251.0 Hypoglycemic coma 775.9 Unspecified endocrine and metabolic disturbances specific to the fetus and 251.1 Other specified hypoglycemia newborn (ill premature infant with hypoproteinemia and acidosis 251.2 Hypoglycemia, unspecified 780.3 Convulsions 251.3 Postsurgical hypoinsulinemia 996.81 Complications of transplanted kidney (hyperparathyroidism) 253.0 Acromegaly and gigantism 996.83 Complications of transplanted heart 276.0 Hypersmolality and/or hypernatremia V42.0 Organ or tissue replaced by transplant, kidney (with secondary 276.1 Hyposmolality and/or hypernatremia hyperparathroidism) 276.5 Volume depletion V42.1 Organ or tissue replaced by transplant, heart 276.7 Hyperpotassemia V56.0 Extracorporeal dialysis ( with secondary hyperparathyroidism) 276.8 Hypopotassemia 276.9 Electrolyte and fluid disorders not elsewhere classified 345.10-345.11 Generalized convulsive epilepsy 348.3 encephalopathy, unspecified 357.9 Unspecified inflammatory and toxic neuropathy 368.8 Other specified visual disturbance 577 Acute pancreatitis 577.1 Chronic pancreatitis 607.84 Impotence of organic origin 648.00-648.04 Diabetes mellitus in mother complicating pregnancy, childbirth, or puerperium 648.80-648.84 Abnormal glucose tolerance in mother complicating pregnancy, childbirth, or puerperium 780.2 Syncope and collapse

58 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs IDAHO

DIGOXIN THERAPEUTIC DRUG ASSAY 130.5 Hepatitis due to toxoplasmosis 153.0-153.9 Malignant neoplasm of colon (ANY SOURCE) 154.0 Malignant neoplasm of rectosigmoid junction 154.1 Malignant neoplasm of rectum Idaho Medicare Part B/Local Medical Review Policy 154.8 Malignant neoplasm of other sites Medicare Bulletin GR 98-3 May/June 1998 155.0 Malignant neoplasm of liver, primary 155.2 Malignant neoplasm of liver, not specified as primary or secondary CPT: 80162 Digoxin 157.0-157.9 Malignant neoplasm of pancreas 174.0-174.9 Malignant neoplasm of female breast 242.00-242.91 Thyrotoxicosis with or without goiter 175.0-175.9 Malignant neoplasm of male breast 243 Congenital hypothyroidism 186.9 Malignant neoplasm of other and unspecified testis 244.0-244.9 Acquired hypothyroidism 197.5 Secondary malignant neoplasm of large intestine and rectum 245.0-245.9 Thyroiditis 197.7 Secondary malignant neoplasm of liver, specified as secondary 275.2 Disorders of magnesium metabolism 197.8 Secondary malignant neoplasm of other digestive organs and spleen 275.4 Disorders of calcium metabolism 198.81 Secondary malignant neoplasm of breast 276.3 Alkalosis 211.5 Benign neoplasm of liver, biliary passages 276.4 Mixed acid-base balance disorder 211.6 Benign neoplasm of pancreas, except islets of Langerhans 276.8 Hypopotassemia 230.3 Carcinoma is situ of colon 402.00-402.91 Hypertensive heart disease 230.8 Carcinoma in situ of liver, biliary system 404.00-404.93 Hypertensive heart and renal disease 230.9 Carcinoma in situ of other and unspecified digestive organs 410.00-410.92 Acute myocardial infarction 235.2 Neoplasm of uncertain behavior of stomach, intestines, rectum 411.0-411.89 Other acute and subacute forms of ischemic heart disease 235.3 Neoplasm of uncertain behavior of liver, biliary passages 412 Old myocardial infarction 235.5 Neoplasm of uncertain behavior of other and unspecified digestive organs 413.0-413.9 Angina pectoris 238.3 Neoplasm of uncertain behavior of breast 414.00-414.9 Other forms of chronic ischemic heart disease 239.0 Neoplasm of unspecified nature of digestive system 425.0-425.9 Cardiomyopathy 275.0 Disorders of iron metabolism 426.0-426.9 Conduction disorders 275.1 Disorders of copper metabolism 427.0-427.9 Cardiac dysrhythmias 277.00 Cystic fibrosis without mention of meconium ileus 428.0-428.9 Heart failure 291.0 Alcohol withdrawal delirium 429.2 Cardiovascular disease, unspecified 291.1 Alcohol amnestic syndrome 514 Pulmonary congestion and hypostasis 291.2 Other alcoholic dementia 557.1 Chronic vascular insufficiency of intestine 291.3 Alcohol withdrawal hallucinosis 579.9 Unspecified intestinal malabsorption 291.4 Idiosyncratic alcohol intoxication 584.5-584.9 Acute renal failure 291.5 Alcoholic jealousy, paranoia, pyschosis 585 Chronic renal failure 303.00-303.03 Acute alcoholic intoxication 588.8 Other specified disorders resulting from impaired renal function 303.90-303.93 Other and unspecified alcohol dependence 746.1 Tricuspid atresia and stenosis, congenital 305.00-305.92 Nondependent abuse of drugs 746.3 Congenital stenosis of aortic valve 570 Acute and subacute necrosis of liver 746.4 Congenital insufficient of aortic valve 571.0-571.9 Chronic liver disease and cirrhosis 746.5 Congenital mitral stenosis 572.0-572.8 Liver abscess and sequealae of chronic liver disease 746.6 Congenital mitral insufficiency 574.00-574.51 Cholelithiasis 746.81 Other specified anomalies of heart, subaortic stenosis 575.0-575.9 Other disorders of gallbladder 746.89 Other specified anomalies of heart 576.0-576.9 Other disorders of biliary tract 746.9 Unspecified anomaly of heart 577.0-577.9 Disease of pancreas 747.22 Atresia and stenosis of aorta 774.4 Perinatal jaundice due to hepatocellular damage 783.0 Anorexia 789.1 Hepatomegaly 787.01-787.03 Nausea and Vomiting V11.3 Personal history of alcoholism 972.0 Cardiac rhythm regulators V58.69 Long-term (current) use of other medications 972.1 Poisoning by cardiotonic glycosides and drugs of similar action 995.2 Unspecified adverse effect of drug, medicinal and biological substance V72.81 Preoperative cardiovascular examination GLYCATED HEMOGLOBIN V58.69 Long-term (current) use of other medications Idaho Medicare Part B/Local Medical Review Policy Medicare Bulletin GR 96-1/ Effective March 15, 1996 GAMMA GLUTAMYLTRANSFERASE (GGT) CPT: 83036 Glycated Hemoglobin (Glycosylated hemoglobin, total fasting Idaho Medicare Part B/Local Medical Review Policy hemoglobin, glychohemoglobin) Medicare Bulletin GR 98-3 May/June 98

250.00-250.93 Diabetes mellitus CPT: 82977

017.90-017.96 Tuberculosis of other specified organs, confirmation unspecified 070.0-070.9 Viral hepatitis 072.71 Mumps hepatitis 074.8 Other specified diseases due to Coxsackie virus 075 Infectious monolucleosis 078.5 Cytomegaloviral disease 084.9 Other pernicious complications of malaria

SEPTEMBER 2000 59 LMRPs IDAHO (509) 927-6250 • 1-800-433-1583

IMMUNOASSAY FOR TUMOR ANTIGEN CPT: 86316 CA 27.29 Idaho medicare Part B/Local Medical Review Policy Medicare Bulletin GR 97-2, April/May 1997 174.0-174.9 Malignant neoplasm of the female breast 175.0 Malignant neoplasm of the male breast CPT: 82105 Alpha-fetoprotien; serum 175.9 198.81 Secondary malignant neoplasm of breast 070.22-070.23 Chronic viral hepatitis B with hepatic coma; with or without mention of hepatitis delta 070.32-070.33 Chronic viral hepatitis B without mention of hepatic coma, with or without mention of hepatitis delta 070.44 Chronic hepatitis C with hepatic coma 070.54 Chronic hepatitis C without mention of hepatic coma 155.0-155.2 Malignant neoplasm of the liver and intrahepatic bile ducts 183.0 Malignant neoplasm, ovary 186.0 Malignant neoplasm of undescended testis 186.9 Malignant neoplasm, other and unspecified testis 571.40 Chronic hepatitis, unspecified 571.41 Chronic persistent hepatitis 571.49 Other chronic hepatitis 789.1 Hepatomegaly 197.7 Secondary malignant neoplasm of liver, specified as secondary 198.6 Secondary malignant neoplasm of ovary 198.82 Secondary malignant neoplasm, genital organs V10.43 Personal history of malignant neoplasm, ovary V10.47 Personal history of malignant neoplasm, testis

CPT: 82378 Carcinoembryonic antigen (CEA)

150-154.8 Malignant neoplasm of small intestine, colon and rectum 159.0 Malignant neoplasm of other ill defined sites within the intestinal tract 174.0-174.9 Malignant neoplasm of female breast 175.0-175.9 Malignant neoplasm of male breast 197.4 Secondary malignant neoplasm of small intestine 197.5 Secondary malignant neoplasm of large intestine 235.2 Neoplasm of uncertain behavior of stomach, intestines and rectum V10.03 Personal history of malignant neoplasm, esophagus V10.05 Personal history of malignant neoplasm, large intestine V10.06 Personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus

CPT: 84702 Gonadotropin, chorionic (hCG): quantitative CPT: 84703 …qualitative

181 Malignant neoplasm of placenta 183.0 Malignant neoplasm, ovary 186.0 Malignant neoplasm of undescended testis 186.9 Malignant neoplasm, other and unspecified testis 198.82 Secondary malignant neoplasm of other genital organs V10.43 Personal history of malignant neoplasm, ovary V10.47 Personal history of malignant neoplasm, testis V71.1 Observation for suspected malignant neoplasm

CPT: 86316 CA125 Immunoassay for tumor antigen (eg, cancer antigen 125), each

183.0-183.9 Malignant neoplasm of the ovary and other uterine adnexa 188.0-188.9 Malignant neoplasm of bladder 198.1 Secondary malignant neoplasm of other urinary organs 198.6 Secondary malignant neoplasm of ovary 233.7 Carcinoma in situ of the bladder 239.4 Neoplasms of unspecified nature, bladder V10.43 Personal history of malignant neoplasm, ovary V10.51 Personal history of malignant neoplasm, bladder

60 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs IDAHO

LIPID PROFILE / CHOLESTEROL TESTING 575.2 Obstruction of gallbladder 575.6 Cholesterolosis of gallbladder Idaho Medicare Part B Local Medical Review Policy 576.2 Obstruction of bile duct Medicare Bulletin - GR 97-1, Jan - Mar 1997 576.8 Other specified disorders of biliary tract 577.0-577.9 Pancreatic disease CPT: 80061 Lipid panel (this panel must include procedures 82465, 83718, 579.3 Other and unspecified postsurgical non absorption and 84478) 579.8 Other specified intestinal malabsorption CPT: 82465 Cholesterol, serum, total 581.0-581.9 Nephrotic syndrome CPT: 83715 Lipoprotein, blood; electrophorectic separation and quantitation 584.5 Acute renal failure with lesion of tubular necrosis CPT: 83717 ultracentifugation and quantitation 588.1 Nephrogenic diabetes insipidus CPT: 83718 Lipoprotein, direct measurement; high density cholesterol (HDL 588.8 Other specified disorders resulting from impaired renal function cholesterol) 646.70-646.71 Liver disorders in pregnancy CPT: 83719 VLDL cholesterol 646.73 Antepartum Liver Disorders CPT: 83721 LDL cholesterol 648.10-648.14 Thyroid dysfunction CPT: 84478 Triglycerides 696.0 Psoriatic arthropathy 696.1 Other psoriasis 240.0-246.9 Disorders of the thyroid gland 746.85 Coronary artery anomaly 255.0 Cushing’s syndrome 751.61 Biliary atresia 260 Kwashiorkor 764.10-764.19 “Light-for dates” with signs of fetal malnutrition 261 Nutritional marasmus 786.50 Chest pain, unspecified 262 Other severe, protein-calorie malnutrition V67.51 Following treatment with high risk medication, not elsewhere classified 263.0 Malnutrition of moderate degree 263.1 Malnutrition of mild degree MAGNESIUM 263.8 Other protein-calorie malnutrition 263.9 Other unspecified protein-calorie malnutrition Idaho Medicare Part B/Local Medical Review Policy 270.0 Disturbances of amino-acid transport Medicare Bulletin GR 97-1, Jan-Mar 1997 271.1 Galactosemia 272.0 Pure hypercholesterolemia CPT: 83735 Magnesium 272.1 Pure hyperglyceridemia 272.2 Mixed hyperlipidemia 250.10-250.13 Diabetes with ketoacidosis 272.3 Hyerchylomicronemia 250.20-250.23 Diabetes with hyperosmolarity 272.4 Other and unspecified hyperlipidemia 250.30-250.33 Diabetes with other coma 272.5 Lipoprotein deficiencies 250.40-250.43 Diabetes with renal manifestations 272.6 Lipodystrophy 250.50-250.53 Diabetes with ophthalmic manifestations 272.7 Lipidoses 250.60-250.63 Diabetes with neurological manifestations 272.8 Other disorders of lipoid metabolism 250.70-250.73 Diabetes with peripheral circulatory disorders 272.9 Unspecified disorders of lipoid metabolism 250.80-250.83 Diabetes with other specified manifestations 303.90-303.92 Alcoholism 250.90-250.93 Diabetes with unspecified complication 362.13 Changes in vascular appearance, vascular sheathing of retina 252.0 Hyperparathyroidism 362.82 Retinal exudates and deposits 252.1 Hypoparathyroidism 379.22 Crystalline deposits in vitreous 252.8 Other specified disorders of the parathyroid gland 388.00 Degenerative and vascular disorders of ear, unspecified 252.9 Unspecified disorders of parathyroid gland 401.0-405.99 Hypertension, hypertensive heart disease 255.1 Hyperaldosteronism 410.00-410.92 Acute MI 259.3 Ectopic hormone secretion, not elsewhere classified 411.0-411.1 Other acute and subacute forms of ischemic heart disease 260 Kwashiorkor 411.81 Other acute and subacute forms of Ischemic heart disease, acute Ischemic heart 261 Nutritional marasmus disease without myocardial infarction 262 Other severe, protein-calorie malnutrition 411.89 Other Acute And Subacute Forms Of Ischemic Heart Disease, Other 263.0 Malnutrition of moderate degree 412 Old myocardial infarction 263.8 Other protein-calorie malnutrition 413.0-413.1 Angina pectoris 263.9 Unspecified protein-calorie malnutrition 413.9 Other And Unspecified Angina Pectoris 275.2 Disorders of magnesium metabolism 414.00-414.03 Other forms of chronic ischemic heart disease 275.4 Disorders of calcium metabolism 414.10-414.11 Aneurysm Of Heart (wall) 276.2 Acidosis 414.19 Other Aneurysm Of Heart 276.4 Mixed acid-base balance disorder 414.8-414.9 Other Specified Forms Of Chronic Ischemic Heart Disease 276.5 Volume depletion 427.0-427.9 Paroxysmal ventricular tachycardia, up to and including unspecified cardiac 276.7 Hyperpotassemia dysrhythmia 276.8 Hypopotassemia 428.0-428.9 Heart failure 276.9 Electrolyte and fluid disorders not elsewhere classified 429.2 Cardiovascular disease, unspecified 278.8 Other hyperalimentation 431-437.9 Cerebrovascular disease 286.9 Other and unspecified coagulation defects 438 Late effects of cerebrovascular disease 289.59 Other diseases of spleen 440.0-440.9 Arteriosclerosis 293.0-293.1 Transient acute and subacute delirium 441.00-441.9 Aortic aneurysms 298.9 Unspecified psychosis 443.0-448.9 Peripheral vascular disease 303.90-303.93 Other and unspecified alcohol dependence, chronic alcoholism 557.1 Chronic vascular insufficiency of intestine 307.1 Anorexia nervosa 570-573.9 Liver disease 307.20 Tic disorder, unspecified 574.00-574.51 Cholelithiasis 307.22 Chronic motor tic disorder

SEPTEMBER 2000 61 LMRPs IDAHO (509) 927-6250 • 1-800-433-1583

307.50 Eating disorder, unspecified 636.80-636.82 With unspecified complications 307.51 Bulimia 637.10-637.12 Unspecified abortion; complicated by delay or excessive hemorrhage 307.52 Pica 637.30-637.32 Complicated by renal failure 307.59 Other disorders of eating 637.40-637.42 Complicated by metabolic disorder 333.2 Myoclonus 637.50-637.52 Complicated by shock 333.3 Tics of organic origin 637.60-637.62 Complicated by embolism 336.1 Vascular myelopathies 637.70-637.72 With other specified complications 345.60-345.61 Infantile spasms 637.80-637.82 With unspecified complications 359.5 Myopathy in endocrine diseases classified elsewhere 638.1-638.9 Failed attempted abortion 359.8 Other myopathies 639.1 Delayed or excessive hemorrhage 359.9 Myopathy, unspecified 639.3 Renal failure 410.00-410.02 Acute myocardial infarction of anterolateral wall 639.4 Metabolic disorders 410.10-410.12 Acute myocardial infarction of other anterior wall 639.5 Shock 410.20-410.22 Acute myocardial infarction of inferolateral wall 639.6 Embolism 410.30-410.32 Acute myocardial infarction of inferoposterior wall 639.8 Other and unspecified complications following abortion or ectopic and molar 410.40-410.43 Acute myocardial infarction of other inferior wall pregnancy 410.50-410.52 Acute myocardial infarction of other lateral wall 639.9 Unspecified complication following abortion or ectopic and molar pregnancy 410.60-410.62 Acute myocardial infarction, true posterior wall 640.00-640.01 Hemorrhage in early pregnancy 410.70-410.72 Acute myocardial infarction, subendocardial 640.03 Threatened Abortion, Antepartum 410.80-410.82 Acute myocardial infarction of other specified site 640.80-640.81 Other Specified Hemorrhage In Early Pregnancy, Unspecified As To Episode Of 410.90-410.92 Acute myocardial infarction of unspecified site Care 411.81 Coronary occlusion without myocardial infarction 640.83 Other Specified Hemorrhage In Early Pregnancy, Antepartum 415.11 Iatrogenic pulmonary embolism and infarction 640.90-640.91 Unspecified Hemorrhage In Early Pregnancy, Unspecified As To Episode Of Care 415.19 Other pulmonary embolism and infarction 640.93 Unspecified Hemorrhage In Early Pregnancy, Antepartum 427.0-427.2 Paroxysmal supraventricular, ventricular, and unspecified tachycardia 641.00-641.01 Antepartum hemorrhage, abruptio placentae, and placenta previa 427.31-427.32 Atrial fibrillation and flutter 641.03 Placenta Previa Without Hemorrhage, Antepartum 427.41-427.42 Ventricular fibrillation and flutter 641.10-641.11 Hemorrhage From Placenta Previa, Unspecified As To Episode Of Care 427.5 Cardiac arrest 641.13 Hemorrhage From Placenta Previa, Antepartum 427.60-427.61 Premature beats 641.20-641.21 Premature Separation Of Placenta, Unspecified As To Episode Of Care 427.69 Premature beats, other 641.23 Premature Separation Of Placenta, Antepartum 427.81 Sinoatrial node dysfunction 641.30-641.31 Antepartum Hemorrhage Associated With Coagulation Defects, Unspecified As 427.89 Other specified cardiac dysrhythmias To Episode Of Care 427.9 Cardiac dysrhythmia, unspecified 641.33 Antepartum Hemorrhage Associated With Coagulation Defects 429.79 Other certain sequelae of myocardial infarction, not elsewhere classified 641.80-641.81 Other Antepartum Hemorrhage, Unspecified As To Episode Of Care 429.89 Other ill-defined heart disease 641.83 Other Antepartum Hemorrhage 458.0-458.2 Hypotension 641.90-641.92 Unspecified Antepartum Hemorrhage, Unspecified As To Episode Of Care 458.9 Hypotension, unspecified 641.93 Unspecified Antepartum Hemorrhage 536.2 Persistent vomiting 642.00-642.04 Hypertension complicating pregnancy, childbirth, and the puerperium 579.3 Other and unspecified postsurgical nonabsorption 642.10-642.14 Hypertension Secondary To Renal Disease, Complicating Pregnancy, Childbirth, 579.8 Other specified intestinal malabsorption And The Puerperium, Unspecified As To Episode Of Care 579.9 Unspecified intestinal malabsorption 642.20-642.24 Other Pre-existing Hypertension Complicating Pregnancy, Childbirth, And The 584.5-584.9 Acute renal failure Puerperium, Unspecified As To Episode Of Care 585 Chronic renal failure 642.30-642.34 Transient Hypertension Of Pregnancy, Unspecified As To Episode Of Care 586 Renal failure, unspecified 642.40-642.44 Mild Or Unspecified Pre-eclampsia, Unspecified As To Episode Of Care 588.8 Other specified disorder resulting from impaired renal function 642.50-642.54 Severe Pre-eclampsia, Unspecified As To Episode Of Care 593.81 Vascular disorders of kidney 642.60-642.64 Eclampsia Complicating Pregnancy, Childbirth Or The Puerperium, Unspecified As 632 Missed abortion To Episode Of Care 634.10-634.12 Spontaneous abortion; complicated by delay or excessive hemorrhage 642.70-642.74 Pre-eclampsia Or Eclampsia Superimposed On Pre-existing Hypertension, 634.30-634.32 Complicated by renal failure Complicating Pregnancy, Childbirth, Or The Puerperium, Unspecified As To 634.40-634.42 complicated by metabolic disorder Episode Of Care 634.50 Complicated by shock 642.90-642.94 Unspecified Hypertension Complicating Pregnancy, Childbirth, Or The Puerperium, 634.60-634.62 Complicated by embolism Unspecified As To Episode Of Care 634.70-634.72 With other specified complications 643.10-643.11 Hyperemesis Gravidarum With Metabolic Disturbance, Unspecified As To Episode 634.80-634.82 With unspecified complications Of Care 635.10-635.12 Legally induced abortion; complicated by delay or excessive hemorrhage 643.13 Hyperemesis Gravidarum With Metabolic Disturbance, Antepartum 635.30-635.32 Complicated by renal failure 643.20-643.21 Late Vomiting Of Pregnancy, Unspecified As To Episode Of Care 635.40-635.42 Complicated by metabolic disorder 643.23 Late Vomiting Of Pregnancy, Antepartum 635.50-635.52 Complicated by shock 643.80-643.81 Other Vomiting Complicating Pregnancy, Unspecified As To Episode Of Care 635.60-635.62 Complicated by embolism 643.83 Other Vomiting Complicating Pregnancy, Antepartum 635.70-635.72 With other specified complications 643.90-643.91 Unspecified Vomiting Of Pregnancy, Unspecified As To Episode Of Care 635.80-635.82 With unspecified complications 643.93 Unspecified Vomiting Of Pregnancy, Antepartum 636.10-636.12 Illegally induced abortion; complicated by delay or excessive hemorrhage 646.20-646.24 Unspecified renal disease in pregnancy, without mention of hypertension 636.30-636.32 Complicated by renal failure 646.80-646.84 Other specified complications of pregnancy 636.40-636.42 Complicated by metabolic disorder 646.90-646.91 Unspecified complications of pregnancy 636.50-636.52 Complicated by shock 646.93 Unspecified Antepartum Complication 636.60-636.62 Complicated by embolism 648.00-648.04 Diabetes mellitus 636.70-636.72 With other specified complications 648.90-648.94 Other current conditions in the mother classifiable elsewhere, but complicating

62 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs IDAHO

pregnancy, childbirth, or puerperium V56.8 Other dialysis 655.80-655.81 Other known or suspected fetal abnormality, not elsewhere classified V58.1 Chemotherapy, (cis-platinum) 655.83 Other known or suspected fetal abnormality, not elsewhere classified V58.69 Long term (current) use of other medications (high risk) 655.90-655.91 Unspecified fetal abnormality 655.93 Unspecified fetal abnormality PARTIAL THROMBOPLASTIN TIME 656.00-656.01 Fetal-maternal hemorrhage 656.03 Fetal-maternal hemorrhage Idaho Medicare Part B/Local Review Policy 656.30-656.31 Fetal distress Medicare Bulletin ID 97-019/ Effective June 15, 1998 656.33 Fetal distress 656.40-656.41 Intrauterine death CPT: 85730 Thromboplastin time, partial (PTT): plasma or whole blood 656.43 Intrauterine death 666.00 Postpartum hemorrhage 286.0 Congenital factor VIII disorder - Hemophilia A 666.02 Postpartum hemorrhage 286.1 Congenital factor IX disorder - Hemophilia B 666.04 Postpartum hemorrhage 286.2-286.3 Other congenital factor deficiencies 666.10 Postpartum hemorrhage 286.4 Von Willebrand’s diseases 666.12 Postpartum hemorrhage 286.5 Hemorrhagic disorder due to circulating anticoagulants 666.14 Postpartum hemorrhage 286.6 Defibrination syndrome 666.20 Postpartum hemorrhage 286.7 Acquired coagulation factor deficiency 666.22 Postpartum hemorrhage 287.9 Unspecified hemorrhagic conditions 666.24 Postpartum hemorrhage 570 Acute and subacute necrosis of liver 668.10-668.14 Cardiac complications 964.2 Poisoning by agents primarily affecting blood constituents, anticoagulants 668.80-668.84 Other complications of anesthesia or other sedation in labor and delivery 668.90-668.94 Unspecified complication of anesthesia and other sedation PLATELET COUNTS 669.10-669.14 Shock during or following labor and delivery 669.20-669.24 Maternal hypotension syndrome Idaho Medicare Part B/Local Medical Review Policy 669.30-669.32 Acute renal failure following labor and delivery Medicare Bulletin ID 97-027/ Effective June 15, 1998 669.34 Acute renal failure following labor and delivery 669.40-669.44 Other complications of obstetrical surgery and procedures CPT: 85585 Platelet; estimation on smear only 669.80-669.84 Other complications of delivery CPT: 85590 Platelet count, manual 669.90-669.94 Unspecified complication of labor and delivery CPT: 85595 Platelet count, automated 673.20-673.24 Obstetrical blood-clot embolism 728.9 Unspecified disorders of muscle, ligament, and fascia 238.4 Polycythemia vera 760.0 Maternal hypertensive disorders 266.2 Deficiency of B complex components, other 760.1 Maternal renal and urinary tract diseases 280.0 Iron deficiency anemia secondary to blood loss (chronic) 760.4 Maternal nutrition disorders 280.8 Other specified iron deficient anemias 760.71 Alcohol affecting fetus via placenta or breast milk 281.2 Folate-deficiency anemia 760.8 Other specified maternal conditions affecting fetus or newborn 281.3 Other specified megaloblastic anemia not elsewhere classified 763.8 Other specified complications of labor and delivery affecting fetus or newborn 281.9 Unspecified deficiency anemia 763.9 Unspecified complications of labor and delivery affecting fetus or newborn 282.2 Anemias due to disorders of glutathione metabolism 780.01-780.02 Coma 284.0 Constitutional aplastic anemia 780.09 Other alterations of consciousness 284.8 Other specified aplastic anemia 780.2 Syncope and collapse 284.9 Aplastic anemia, unspecified 780.3 Convulsions 285.1 Acute posthemorrhagic anemia 780.79 Malaise and fatigue 286.6 Defibrination syndrome 781.0 Abnormal involuntary movements 286.9 Other and unspecified coagulation defects 781.7 Tetany 287.0-287.9 Purpura and other hemorrhagic conditions 783.0 Anorexia 289.0 Polycythemia, secondary 783.2 Abnormal loss of weight 289.6 Familial polycythemia 783.3 Feeding difficulties and mismanagement 289.9 Unspecified diseases of blood and blood-forming organs 783.9 Other symptoms concerning nutrition, metabolism, and development 446.6 Thrombotic microangiopathy 785.0 Tachycardia, unspecified 666.32 Postpartum coagulation defects, delivered, with mention of postpartum 785.50-785.51 Cardiogenic shock; shock unspecified complication 785.59 Shock, other 666.34 Postpartum coagulation defects, postpartum condition or complication 790.6 Other abnormal blood chemistry 719.10-719.19 Hemarthrosis 794.31 Abnormal electrocardiogram 759.0 Anomalies of spleen 794.4 Abnormal kidney test 776.1 Transient neonatal thrombocytopenia 796.2 Elevated blood pressure reading without diagnosis of hypertension 776.4 Polycythemia neonatorum 799.4 Cachexia 782.7 Spontaneous ecchymoses (petechiae) 958.4 Traumatic shock 789.2 Splenomegaly 995.2 Unspecified adverse effect of drug, medicinal and biological substance, V45.89 Other post surgical status amphotericin B V58.61 Long term (current) use of anticoagulants 997.1 Cardiac complications V58.69 Long term (current) use of high risk medications 998.0 Postoperatvie shock V67.1 Follow up exam following radiotherapy/chemotherapy 998.9 Unspecified complication of procedure, not elsewhere classified V67.51 Follow up exam following completed treatment with high risk medication (NOC) 999.9 Other and unspecified complications of medical care, not elsewhere classified, V72.81 Pre-operative cardiovascular examination dialysis V72.82 Pre-operative respiratory examination V56.0 Extracorporeal dialysis V72.83 Other specified pre-operative examination V72.84 Preoperative examination, unspecified V72.85 Other specified examination SEPTEMBER 2000 63 LMRPs IDAHO (509) 927-6250 • 1-800-433-1583

PROTHROMBIN TIME 572.8 Other sequelae of chronic liver disease 573.3 Hepatitis, unspecified Idaho Medicare Part B/Local Medical Review Policy 573.9 Unspecified disorder of liver Medicare Bulletin GR 96-4, July/August 1996 577.0 Acute pancreatitis 578.0-578.9 Gastrointestinal hemorrhage CPT: 85610 Prothrombin Time 579.2 Blind loop syndrome 599.7 Hematuria 070.0-070.9 Viral hepatitis 671.20-671.54 Venous complications in pregnancy and the puerperium 285.1 Acute posthemorrhagic anemia 671.90-671.94 Unspecified venous complication 286.0-286.9 Coagulation defects 673.00-673.84 Obstetrical pulmonary embolism 287.0-287.9 Purpura and other hemorrhagic conditions 719.10-719.99 Hemarthrosis (5th digits 5, 6, and 9 allowed only) 290.40-290.43 Arteriosclerotic dementia 746.0-746.9 Other congenital anomalies of heart 325 Phlebitis and thrombophlebitis of intracranial venous sinuses 782.7 Spontaneous ecchymosis 362.30-362.37 Retinal vascular occlusion 784.7 Epistaxis 386.2 Vertigo of central origin 784.8 Hemorrhage from throat 386.50 Labyrinthine dysfunction, unspecified 786.3 Hemoptysis 394.0-394.9 Diseases of the mitral valve 789.1 Hepatomegaly 395.0 Rheumatic aortic stenosis 789.5 Ascites 395.2 Rheumatic aortic stenosis with insufficiency 790.92 Abnormal coagulation profile 396.0-396.9 Diseases of mitral and aortic valves 852.00-852.59 Subarachnoid, subdural, and extradural hemorrhage, following injury 397.1 Rheumatic diseases of pulmonary valve 964.2 Poisoning by anticoagulant 397.9 Rheumatic diseases of endocardium, valve unspecified 995.2 Unspecified adverse effect of drug, medicinal and biological substance (due to 398.0 Rheumatic myocarditis correct medicinal substance properly administered) 398.90 Rheumatic heart disease, unspecified V12.3 Personal history of disease of blood and blood forming organs 398.91 Rheumatic heart failure (congestive) V15.1 Personal history of surgery to heart and great vessels 398.99 Other Rheumatic heart disease V42.2 Heart valve replaced by transplant 410.00-410.92 Acute myocardial infarction V42.7 Liver replaced by transplant 411.1 Intermediate coronary syndrome V43.2 Heart replacement by means other than transplant 411.81-411.89 Other and acute coronary occlusion without myocardial infarction V43.3 Heart valve replaced by means other than transplant 413.0-413.9 Aninga pectoris V43.4 Blood vessel replacement by means other than transplant 414.10 Aneurysm of heart wall V43.60 Unspecified joint replacement by means other than transplant 414.00-414.03 Coronary atherosclerosis V72.84 Pre-operative examination, unspecified 414.8 Other specified forms of chronic ischemic heart disease 414.9 Chronic ischemic heart disease, unspecified PROSTATE SPECIFIC ANTIGEN 415.0-415.19 Acute pulmonary heart disease 416.9 Chronic pulmonary heart disease, unspecified Idaho Medicare Part B/Local Medical Review Policy 424.0 Mitral valve disorders Medicare Bulletin GR 96-4, July/August 1996 424.1 Aortic valve disorders 425.0-425.9 Cardiomyopathy CPT: 84153 Prostate Specific Antigen (PSA) 427.0-427.9 Cardiac dysrhthmia 428.0-428.9 Heart Failure 185 Malignant Neoplasm of Prostate 429.1-429.4 Ill-defined descriptions and complications of heart disease 188.5 Malignant Neoplasm of bladder neck 429.79 Mural thrombus 188.8 Malignant Neoplasm of Other Specified sites of Bladder 432.0-432.9 Other and unspecified intracranial hemorrhage 196.5 Secondary and Unspecified Malignant Neoplasm of Lymph Nodes of Inguinal 433.00-433.91 Occlusion and stenosis of precerebral arteries Region and Lower Limb 434.00-434.91 Occlusion of cerebral arteries 196.6 Secondary and Unspecified Malignant Neoplasm of Intrapelvic Lymph Nodes 435.0-435.9 Transient cerebral ischemia 196.8 Lymph nodes of multiple sites 436 Acute, but ill-defined cerebrovascular disease 198.5 Bone and bone marrow 437.0 Cerebral atherosclerosis 198.82 Secondary Malignant Neoplasm of Genital Organs 437.1 Other generalized ischemic cerebrovascular disease 233.4 Carcinoma in Situ of Prostate 437.6 Nonpyogenic thrombosis of intracranial venous sinus 236.5 Neoplasm of Uncertain Behavior of Prostate 440.0-440.9 Atherosclerosis 239.5 Neoplasm of unspecified nature of prostate 443.0-443.9 Other peripheral vascular disease 790.93 Elevated Prostate Specific Antigen (PSA) 444.0-444.9 Arterial embolism and thrombosis V10.46 Personal History of Malignant Neoplasm of Prostate 447.1 Stricture of artery V71.1 Observation for suspected malignant neoplasm 451.0-451.9 Phlebitis and thrombophlebitis 452 Portal vein thrombosis 453.0-453.9 Other venous embolism and thrombosis 459.0 Hemorrhage, unspecified 459.1 Postphlebitis syndrome 459.2 Compression of vein 459.81 Venous (peripheral) insufficiency, unspecified 514 Pulmonary congestion and hypostasis 569.3 Hemorrhage of rectum and anus 571.0-571.9 Chronic liver disease and cirrhosis 572.2 Hepatic coma 572.4 Hepatorenal syndrome

64 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs IDAHO

PROSTATIC ACID PHOSPHATASE (PAP) SEDIMENTATION RATE, ERYTHROCYTE, Idaho Medicare Part B/Local Medical Review Policy AUTOMATED AND NON AUTOMATED Medicare Bulletin GR 97-6/ Effective December 20, 1997 Idaho Medicare Part B/Local Medical Review Policy Medicare Bulletin ID 98-006/ Effective March 15, 1999 CPT: 84066 Phosphatase, acid; prostatic

CPT: 85651 Sedimentation rate, erythrocyte;non automated 185 Malignant neoplasm of prostate CPT: 85652 automated 198.5 Secondary malignant neoplasm of bone and bone marrow 222.2 Benign neoplasm of prostate 038.0 Streptococcal septicemia 233.4 Carcinoma in situ; prostate 041.0-041.09 Streptococcus, up to and including other strepococcus 236.5 Neoplasm of uncertain behavior; prostate 136.3 Pneumocystosis 239.5 Neoplasms of unspecified nature; other genitourinary organs 201.9 Hodgkin’s Disease, unspecified 790.93 Elevated prostate specific antigen (PSA) 245.1 Subacute Thyroiditis V10.46 Personal history of malignant neoplasm; prostate 245.2 Chronic lymphocytic thyroiditis V72.84 Preoperative examination, unspecified 274.0 Gouty arthropathy 279.4 Autoimmune Disease, NEC RETICULOCYTE COUNTS 287.0 Allergic purpura 390 Rheumatic fever without mention of heart involvement Idaho Medicare Part B/Local Medical Review Policy 391.0 Acute rheumatic pericarditis Medicare Bulletin ID 97-028/ Effective June 15, 1998 391.1 Acute rheumatic endocarditis 391.2 Acute rheumatic myocarditis CPT: 85044 Blood count; reticulocyte 391.8 Other acute rheumatic heart disease CPT: 85045 Blood count; reticulocyte count, flow cytometry 420.0 Acute pericarditis/disease classified elsewhere 420.90-420.99 Other and unspecified pericarditis 280.0-285.9 Anemias 421.0 Acute and subacute bacterial endocarditis 421.1 Acute and subacute infective endocarditis/disease classified elsewhere RHEUMATOID FACTOR TEST 421.9 Acute endocarditis, unspecified 422.0 Acute myocarditis/disease classified elsewhere Idaho Medicare Part B/Local Medical Review Policy 422.90-422.99 Other and unspecified acute myocarditis Medicare Bulletin GR 98-5, Jan-Mar 1997 425.4 Cardiomyopathies 430-437.9 Cerebrovascular Disease CPT: 86430 Rheumatoid factor test; qualitative 446.0 Polyarteritis nodosa CPT: 86431 … quantitative 446.1-446.4 Polyarteritis nodosa, up to and including Giant cell arteritis 446.5 Giant cell arteritis 015.00-015.26 Tuberculosis of bones and joints 447.6 Arteritis, unspecified 015.80-015.96 486 Pneumonia, organism unspecified 030.9 Leprosy, unspecified 515 Post inflammatory pulmonary fibrosis 075 Infectious mononucleosis 555.0-555.9 Regional enteritis 095.8 Other specified forms of late symptomatic syphilis 558.1-558.9 Other noninfectious gastroenteritis and colitis 135 Sarcoidosis 580.9 Acute glomerulonephritis, NOS, hemorrhagic 273.2 Other paraproteinemias 585 Chronic renal failure 274.0 Gouty arthropathy 614.9 Pelvic inflammatory disease 421.9 Acute endocarditis, unspecified 625.0 Dyspareunia 446.5 Giant cell arteritis 682.9 Other cellulitis and abscess, unspecified 516.3 Idiopathic fibrosing alveolitis 695.2 Erythemea nodosum 571.9 Unspecified chronic liver disease without mention of alcohol 695.4 Lupus erythematosus (Discoid) 701.0 Circumscribed scleroderma 696.0 Psoriatic arthropathy 710.0-710.4 Diffuse diseases of connective tissue 710.0 Systemic lupus erythematosus 710.9 Unspecified diffuse connective tissue disease 710.1 Systemic sclerosis 711.10-711.19 Arthropathy associated with infections 710.2 Sicca syndrome 711.20-711.29 710.3 Dermatomyositis 711.30-711.39 710.4 Polymyositis 712.10-712.39 Crystal arthropathies 710.5 Eosinophilia myalgia syndrome 712.80-712.99 710.8 Other specified diffuse diseases of connective tissue 713.0-713.6 Arthropathy associated with other disorders classified elsewhere 710.9 Unspecified diffuse connective tissue 714.0-714.2 Rheumatoid arthritis and other inflammatory polyarthropathies 711.00-711.09 Pyogenic arthritis 714.30-714.33 Juvenile chronic polyarthritis 711.10-711.19 Arthropathy associated with Reiter’s disease and non-specific urethritis 714.4 Chronic postrheumatic arthropathy 711.20-711.29 Arthropathy in Behcet’s syndrome 714.81 Rheumatoid lung 711.30-711.39 Postdysenteric arthropathy 714.89 Other specified inflammatory polyarthropathies 711.40-711.49 Arthropathy associated with other bacterial diseases 714.9 Unspecified inflammatory polyarthropathy 711.50-711.59 Arthropathy associated with other viral diseases 725 Polymyalgia rheumatica 711.60-711.69 Arthropathy associated with mycoses 711.70-711.79 Arthropathy associated helminthiasis 711.80-711.89 Arthropathy associated with other infectious and parasitic diseases 711.90-711.99 Unspecified crystal arthropathy

SEPTEMBER 2000 65 LMRPs IDAHO (509) 927-6250 • 1-800-433-1583

714.0 Rheumatoid arthritis 250.01-250.91 Insulin dependent diabetes mellitus 714.1 Felty’s syndrome 275.0 Disorders of iron metabolism 714.2 Other rheumatoid arthritis with visceral or systemic involvement 280.0 Iron deficiency anemia secondary to blood loss (chronic) 714.30-714.33 Juvenile chronic polyarthritis 280.1 Iron deficiency anemia secondary to inadequate dietary intake 714.4 Chronic postrheumatic arthropathy 280.8 Other specified iron deficiency anemias 714.81-714.89 Other specified inflammatory polyarthropathies 280.9 Iron deficiency anemia, unspecified 714.9 Unspecified inflammatory polyarthropathies 282.4 Thalassemia 715.00-715.98 Osteoarthrosis and allied disorders 282.60 Sickle cell anemia, unspecified 716.00-716.09 Kaschin-Beck disease 282.63 Sickle cell/hb-c disease 716.20-716.29 Allergic arthritis 282.69 Other sickle cell anemia 716.50-716.59 Unspecified polyarthropathy or polyarthritis 282.7 Other hemoglobinopathies 716.60-716.68 Unspecified monarthritis 285.0 Sideroblastic anemia 716.80-716.89 Other specified arthropathy 307.52 Pica 716.90-716.99 Arthropathy, unspecified 425.4 Other primary cardiomyopathies 719.00-719.09 Effusion of joint 536.0 Achlorhydria 719.10-719.19 Hemarthrosis 579.0 Celiac disease 719.20-719.29 Villonodular synovitis 579.2 Blind loop syndrome 719.30-719.39 Palindromic rheumatism 579.8 Other and unspecified intentional nonabsorption 719.40-719.49 Arthralgia 579.9 Unspecified intestinal malabsorption 720.0 Ankylosing spondylitis 585 Chronic renal failure 720.1 Spinal enthesopathy 608.3 Atrophy of testis 720.2 Sacroillitis, not elsewhere classified 648.20-648.24 Anemia complicating pregnancy, childbirth, or the puerperium 720.81-720.89 Other inflammatory spondylopathies 713.0 Arthropathy associated with other endocrine and metabolic disorders; code first 720.9 Unspecified inflammatory spondylopathy underlying disease as hemochromatosis (275.0) 721.0 Cervical spondylosis w/o myelopathy 790.6 Other abnormal blood chemistry, iron 721.1 Cervical spondylosis with myelopathy 999.8 Other transfusion reaction 721.2 Thoracic or lumbar spondylosis with myelopathy V56.0 Extracorporeal dialysis 721.3 Lumbosacral spondylosis w/o myelopahty V56.8 Peritoneal dialysis 721.41-721.42 Thoracic spondylosis w/o myelopathy 725 Polymyalgia rheumatica 727.00 Synovitis and tenosynovitis, unspecified SYPHILIS TEST (RPR) 727.01 Synovitis and tenosynovitis in diseases classified elsewhere Idaho Medicare Part B/Local Medical Review Policy 727.04 Radial styloid tenosynovitis Medicare Bulletin GR 98-5 Sept/Oct 1998 727.05 Other tenosynovitis of hand and wrist 727.06 Tenosynovitis of foot and ankle CPT: 86592 Syphilis test; qualitative (eg, VDRL, RPR, ART) 727.09 Other synovitis and tenosynovitis CPT: 86593 … quantitative 727.2 Specific bursitis often of occupational origin CPT: 86781 Treponema Pallidium, confimatory test (eg, FTA-abs) 727.3 Other bursitis 729.0 Rheumatism, unspecified and fibrositis 042 Human immunodeficiency virus (HIV) disease 729.1 Myalgia and myositis, unspecified 054.10-054.19 Herpes simplex, genital herpes 729.2 Neuralgia, neuritis, and radiculitis, unspecified 078.0-078.19 Other diseases due to viruses and chlamydiae 730.00-730.09 Acute osteomyelitis 090.0-090.9 Congenital syphilis 730.10-730.19 Chronic osteomyelitis 091.0-091.9 Early syphilis symptomatic 730.20-730.29 Unspecified osteomyelitis 092.0-092.9 Early syphilis, latent 730.30-730.39 Periositis w/o mention of osteomyelitis 093.0-093.9 Cardiovascular syphilis 733.00 Osteoporosis, unspecified 094.0-094.9 Neurosyphilis 733.01 Senile osteoporosis 095.0-095.9 Other forms of late syphilis, with symptoms 733.02 Idiopathic osteoparosis 096 Late syphilis, latent 780.6 Pyrexia of unknown origin 097.0-097.9 Other and unspecified syphilis 780.79 Malaise and fatigue 0980-098.89 Gonococcal infections 782.1 Rash and other non-specific skin eruption 099.0-099.9 Other venereal diseases 784.0 Headache 104.0 Nonvenereal endemic syphilis 789.00 Abdominal pain 131.00-131.9 Trichomoniasis 790.1 Elevated sedimentation rate 331.0 Alzheimer’s disease 995.2 Unspecified adverse effect of drug, medicinal and biological substance 331.2 Senile degeneration of brain V67.51 Following treatment with high-risk medication 356.0 Hereditary peripheral neuropathy 356.9 Unspecified hereditary and idiopathic peripheral neuropathy SERUM IRON STUDIES 614.0-614.9 Inflammatory disease of ovary, fallopian tube, pelvic organs and tissues 615.0-615.9 Inflammatory diseases of uterus, except cervix Idaho Medicare Part B/Local Medical Review Policy 616.0-616.9 Inflammatory disease of cervix, vagina, and vulva Medicare Bulletin GR 97-1 760.2 Maternal infections V01.6 Contact with or exposure to venereal diseases CPT: 82728 Ferritin CPT: 83540 Iron CPT: 83550 Iron binding capacity CPT: 84466 Transferrin

66 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs IDAHO

THYROID TESTING INCLUDING TSH 331.0-331.2 Alzheimer’s; Pick’s disease; Senile degeneration of brain 333.1 Essential and other specified forms of tremor Idaho Medicare Part B/Local Medical Review Policy 354.0 Carpal tunnel syndrome Medicare Bulletin GR 97-1, Jan-Mar 1997 356.9 Idiopathic peripheral neuropathy, unspecified 358.1 Myasthenic syndromes in diseases classified elsewhere CPT: 84436 Thyroxine; total 359.5 Myopathy in endocrine diseases classified elsewhere CPT: 84439 Thyroxine; free 368.2 Diplopia CPT: 84443 Thyroid stimulating hormone (TSH) 374.41 Lid retraction or lag CPT: 84479 Triiodothyronine (T-3); resin uptake 376.21 Thyrotoxic exophthalmos CPT: 80091 Thyroid panel, includes Thyroxine; total (84436) and Triiodothyro- 376.22 Exophthalmic ophthalmoplegia nine (T-3), resin uptake (84479) (This has been deleted 4/1/00) 376.30-376.31 Exophthalmic conditions, unspecified and constant CPT: 80092 Thyroid panel with thyroid stimulating hormone (TSH) (84443) 376.33-376.34 Orbital edema or congestion, intermittent exophthalmos and includes (84436, 84479) (This has been deleted 4/1/00) 425.7 Nutritional and metabolic cardiomyopathy 427.0 Paroxysmal supraventricular tachycardia 193 Malignant neoplasm of thyroid gland 427.2 Paroxysmal tachycardia, unspecified 198.82 Secondary malignant neoplasm 427.31 Atrial fibrillation 226 Benign neoplasm of thyroid glands 427.89 Other specified cardiac dysrhythmias 227.3 Benign neoplasm of pituitary gland and craniopharyngeal duct (pouch) 427.9 Cardiac dysrhythmia, unspecified 234.8 Carcinoma in situ of other and unspecified sites 428.0 Congestive heart failure 237.4 Neoplasm of uncertain behavior of other and unspecified endocrine glands 428.1 Left heart failure 239.7 Neoplasm of unspecified nature, thyroid gland 560.1 Paralytic ileus 240.0-240.9 Goiter specified and unspecified 564.0 Constipation 241.0-241.1 Nontoxic goiter 564.7 Megacolon, other than Hirschsprung’s 241.9 Unspecified non toxic goiter 625.3 Menorrhagia/dysmenorrhea 242.00-242.01 Thyrotoxicosis with or without goiter 626.0-626.2 Absence of menstruation; up to and including excessive or frequent menstruation 242.10-242.11 648.10-648.14 Other current conditions in the mother, classifiable elsewhere, but complicating 242.20-242.21 pregnancy, childbirth or puerperium - Thyroid dysfunction 242.30-242.31 676.20-676.24 Engorgement of breast associated with childbirth and disorders of lactation 242.40-242.41 701.1 Keratoderma, acquired (dry skin) 242.80-242.81 703.8 Other specified diseases of nail (brittle nails) 242.90-242.91 704.00 Alopecia, unspecified 243 Congenital hypothyroidism 729.1 Myalgia and myositis, unspecified 244.1-244.3 Acquired hypothyroidism 729.82 Cramp of limb (muscle cramp) 244.8-244.9 733.09 Osteoporosis, drug induced 245.0-245.3 Thyroiditis 750.15 Macroglossia 245.8-245.9 759.2 Anomalies of other endocrine glands 246.1-246.2 Other disorders of thyroid 775.3 Neonatal thyrotoxicosis 246.8 780.09 Alteration of consciousness, other 252.1 Hypoparathyroidism 780.79 Malaise and fatigue 253.1 Other and unspecified anterior pituitary hyperfunction 780.8 Excessive sweating 253.2 Panhypopituitarism 781.0 Abnormal involuntary movements 253.3-253.4 Pituitary dwarfism and other anterior pituitary disorders 781.3 Lack of coordination, ataxia 253.7 Iatrogenic pituatary disorders 782.8 Changes in skin texture 255.2 Adrenogenital disorders 783.1 Abnormal weight gain 255.4 Corticoadrenal insufficiency 783.2 Abnormal loss of weight 258.0-258.9 Polyglandular activity in multiple endocrine adenomatosis, up to and including 784.1 Throat pain polyglandular dysfunction, unspecified 785.0 Tachycardia, unspecified 266.0 Ariboflavinosis 785.1 Palpitations 272.0 Pure hypercholesterolemia 787.2 Dysphagia 272.4 Other and unspecified hyperlipidemia 790.6 Other abnormal blood chemistry, lithium 275.4 Disorders of calcium metabolism 793.2 Nonspecific abnormal findings on radiological and examination of body structure, 276.1 Hyperosmolality and/or hyponatremia intrathoracic organ 278.00 Obesity, unspecified 794.5 Thyroid, abnormal scan or uptake 278.01 Morbid obesity 799.2 Nervousness 290.0 Senile dementia, uncomplicated 290.10-290.13 Presenile dementia URINALYSIS 290.20-290.21 Senile dementia with delusional or depressive features 290.3 Senile dementia with delirium Idaho Medicare Part B/Local Medical Review Policy 293.1 Subacute delirium Medicare Bulletin GR 99-4 July/August 1999/ Effective August 1999 297.1 Paranoia 300.00-300.02 Anxiety states, up to generalized anxiety disorder CPT: 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, 310.1 Organic personality syndrome hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, 311 Depressive disorder, not elsewhere classified urobilinogen, any number of these conditions; with microscopy CPT: 81001 …automated, with microscopy CPT: 81002 …non-automated, without microscopy CPT: 81003 …automated, without microscopy CPT: 81005 Urinalysis, qualitative or semi-quantitative, except immunoassays

SEPTEMBER 2000 67 LMRPs IDAHO (509) 927-6250 • 1-800-433-1583

CPT: 81007 …bacteriuria screen, by non-culture technique, commercial kit (specify 307.1 Anorexia Nervosa type) 307.50 Eating disorder CPT: 81015 …microscopic only 307.51 Bulimia 401.0-401.9 Essential hypertension 008.04 Enterohemorrhagic E. Coli 402.00-402.91 Hypertensive heart disease 010.00-018.96 Tuberculosis 403.00-403.91 Hypertensive renal disease 034.0-034.1 Streptococcal sore throat and scarlet fever 404.00-404.93 Hypertensive heart and renal disease 035 Erysipelas 405.01-405.99 Secondary hypertension 036.0-036.9 Meningococcal infection (036.4 and 036.8 requires 5 digits) 428.0 Congestive heart failure 038.9 Unspecified septicemia 446.0-446.7 Polyarteritis nodosa and allied conditions 042 HIV disease 447.6 Arteritis, unspecified 054.10-054.19 Genital herpes 453.3 Embolism/thrombosis of renal vein 054.3 Herpetic meningoencephalitis 515 Postinflammatory pulmonary fibrosis 072.0 Mumps orchitis 540.0-540.9 Acute appendicitis 078.5-078.6 Cytomegaloviral disease and Hemorrhagic nephrosonephritis 555.0-555.9 Regional enteritis 079.88 Other specified chlamydial infection 556.0-556.3 Ulcerative colitis 079.98 Unspecified chlamydial infection 556.5-556.9 Ulcerative colitis 098.0-098.19 Gonococcal infections, acute of lower and upper genitourinary tract 580.0-580.9 Acute glomerulonephritis (580.8 requires five digits) 098.2-098.39 Gonococcal infections, chronic of lower and upper genitourinary tract 581.0-581.9 Nephrotic syndrome (581.8 requires five digits) 099.3-099.49 Reiter’s disease and other nongonococcal urethritis 582.0-582.9 Chronic glomerulonephritis (582.8 requires five digits) 100.0 Leptospirosis icterohemorrhagica 583.0-583.9 Nephritis and nephropathy not specified as acute or chronic (583.3 requires five 112.1-112.2 Candidiasis of vulva and vagina and of other urogenital sites digits) 112.5 Candidiasis disseminated 584.5-584.9 Acute renal failure 116 Blastomycosis 585 Chronic renal failure 117.7 Zygomycosis 586 Renal failure, unspecified 120.0-120.2 Schistosomiasis 588.8 Other specified disorders resulting from impaired renal function 131.00-131.02 Urogenital trichomoniasis 590.00-590.9 Infections of kidney 185 Malignant neoplasm of prostate 591 Hydronephrosis 187.1-187.9 Malignant neoplasm of penis and other male genital organs 592.0-592.9 Calculus of kidney and ureter 188.0-188.9 Malignant neoplasm of bladder 593.0-593.9 Other disorders of kidney and ureter (593.7 and 593.8 require five digits) 189.0-189.9 Malignant neoplasm of kidney and other unspecified urinary organs 594.0-594.9 Calculus of lower urinary tract 198.0 Secondary malignant neoplasm, kidney 595.0-595.9 Cystitis (595.8 requires five digits) 198.1 Secondary malignant neoplasm, other urinary organs 596.0-596.9 Other disorders of bladder (596.5 requires five digits) 203.00-203.81 Multiple myeloma and immunoproliferative neoplasms 597.0-597.89 Urethritis, not sexually transmitted, and urethral syndrome (597.8 requires fifth 222.1 Benign neoplasm, penis digit) 222.2 Benign neoplasm, prostate 598.00-598.9 Urethral stricture 222.8 Benign neoplasm, other specified sites of male genital organs 599.0-599.9 Other disorders of urethra and urinary tract (599.8 requires five digits) 223.3 Benign neoplasm, bladder 600 Hyperplasia of prostate 223.81 Benign neoplasm, urethra 601.0-601.9 Inflammatory diseases of prostate 223.89 Benign neoplasm, paraurethral glands 602.0-602.9 Other disorders of prostate 233.7 Carcinoma in situ, bladder 604.0 Orchitis, epididymitis, and epididyma-orchitis, with abscess 233.9 Carcinoma in situ, other and unspecified urinary organs 604.90 Orchitis, and epididymitis, unspecified 236.5 Neoplasm of uncertain behavior, prostate 604.91 Orrchitis and epididymitis in diseases classified elsewhere 236.7 Neoplasm of uncertain behavior, bladder 607.0-607.9 Disorders of penis (607.8 requires five digits) 236.91 Neoplasm of uncertain behavior, kidney and ureter 608.0-608.9 Other disorders of male genital organs (608.8 requires five digits) 236.99 Neoplasm of uncertain behavior, other urinary organs 616.1 Vaginitis and vulvovaginitis, unspecified 239.4 Neoplasm of unspecified nature, bladder 617.8 Endometriosis of other specified sites 239.5 Neoplasm of unspecified nature, other genitourinary organs 618 Prolapse of vaginal walls without mention of uterine prolapse 250.00-250.93 Diabetes mellitus 618.8 Other specified genital prolapse 253.5-253.6 Diabetes insipidus; other disorders of neurohypophysis 619.0 Urinary-genital tract fistula, female 263.0-263.9 Malnutrition 625.6 Stress incontinence, female 271.4 Renal glycosuria 625.9 Pelvic pain (Unspecified symptoms associated with female genital tract) 273.0-273.9 Disorders of plasma protein metabolism 642.00-642.94 Hypertension complicating pregnancy 274.0-274.9 Gout 646.20-646.24 Unspecified renal disease in pregnancy 276.0-276.9 Disorders of fluid, electrolyte, and acid-based balance (Dehydration) 646.50-646.54 Asymptomatic bacteriuria in pregnancy 277.00-277.9 Other and unspecified disorders of metabolism 669.80-669.84 Other complications of labor and delivery 282.60-282.63 Sickle cell anemia 710.0-710.4 Diffuse diseases of connective tissue 283.0-283.9 Acquired hemolytic anemias 710.9 Unspecified diffuse connective tissue damage 289.7 Methemoglobinemia 714.0-714.9 Rheumatoid arthritis and other inflammatory polyarthropathies (714.3 and 714.8 294.0-294.9 Other organic psychotic conditions require five digits) 295.00-295.95 Schizophrenic disorders 719.49 Pain in joint, multiple sites 296.20-296.25 Major depressive disorder, recurring episodes 724.2 Low back pain 296.7 Bipolar affective disorder, unspecified 724.5 Backache, unspecified 298.8 Other and unspecified reactive psychosis 752.61 Hypospadias 300.00-300.09 Anxiety states 753.0-753.9 Congenital anomalies of urinary system 306.5 Psychogenic genitourinary malfunction, unspecified 760.1 Maternal renal and urinary tract diseases 306.53 Psychogenic dysuria 780.6 Pyrexia of unknown origin

68 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs IDAHO

760.1 Maternal renal and urinary tract diseases 780.6 Fever 780.79 Malaise and fatigue 782.3 Edema 783.2 Abnormal weight loss 785.59 Shock without mention of trauma, other 788.0-788.9 Symptoms involving urinary system (Most codes require five digits) 789.00-789.9 Other symptoms involving abdomen and pelvis 790.7 Bacterima 790.93 Elevated prostate specified antigen (PSA) 791.0-791.9 Nonspecific findings on examination or urine 793.5-793.6 Nonspecific abnormal findings, genitourinary organs and abdominal area 794.4 Nonspecific abnormal results of function studies, kidney 796.2 Elevated blood pressure reading without diagnosis of hypertension 866.0-866.13 Injury to kidney 867.0-867.1 Injury to bladder and urethra 867.2-867.3 Injury to ureter 867.6 Injury to other specified pelvic organs, without mention of open wound 959.1 Injury to trunk 982.2 Toxic effects of carbon disulfide 985.0 Toxic effects of mercury and its components V10.46 Personal history of malignant neoplasm, prostate V10.5-V10.59 Personal history of malignancy neoplasm, urinary organs V13.00-V13.09 Personal history of other diseases, disorders of urinary tract V22.0-V23.9 Pregnancy V42.0 Organ or tissue replaced by transplant, kidney V44.5 Cystostomy V44.6 Other artificial opening of urinary tract V45.1 Other postsurgical states, renal dialysis status V58.61 Long term (current use) of anticoagulants V58.69 Long term (current use) of other (high risk) medications V67.51 Follow-up examination, following treatment with high-risk medication, not elsewhere classified V72.83 Other specified pre-operative exam

SEPTEMBER 2000 69 LMRPs IDAHO (509) 927-6250 • 1-800-433-1583

70 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON A

LMRPs Washington Medicare A

SEPTEMBER 2000 71 LMRPs WASHINGTON A (509) 927-6250 • 1-800-433-1583 LMRPs – Washington Medicare A

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72 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON A

BACTERIAL CULTURE, URINE 280.0-285.9 Anemias 286.0-289.9 Coagulation defects, purpura, diseases of white blood cells, other diseases of Medicare A Washington and Alaska blood and blood forming organs Local Medical Review Policy Services rendered March 31, 1998 or after 294.0-294.9 Other organic psychotic conditions (chronic) (5/1/96) 295.00-295.95 Schizophrenic disorders (5/1/96) CPT: 87086 Culture, bacterial, urine; quantitative, colony count 296.20-296.25 Major depressive disorder, single episode (5/1/96) CPT: 87087 Commercial kit 296.30-296.35 Major depressive disorder, recurrent episode (5/1/96) CPT: 87088 Identification, in addition to quantitative or commercial kit 296.7 Bipolar affective disorder, unspecified (5/1/96) 298.8 Other and unspecified reactive psychosis (5/1/96) 038.0-038.9 Septicemia 300.00-300.01 Anxiety states (5/1/96) 580.0-589.9 Nephritis, nephrotic syndrome, and nephrosis 307.1 Anorexia nervosa (5/1/96) 590.0-599.9 other diseases of urinary system 307.50 Eating disorder (5/1/96) 600-608.9 Diseases of male genital organs 307.51 Bulimia (5/1/96) 646.5 Asymptomatic bacteriuria in pregnancy 320.0-325. Inflammatory diseases of central nervous system 780.6 Fever 326 Late affects, intracranial abscess or pyogenic infection (1/3/96) 788.0-788.9 Symptoms involving urinary system 360.00-360.19 Endophtalmitis (1/3/96) 790.7 Bacteremia 362.30-362.37 Retinal vascular occlusion 791.0 Proteinuria 363.00-363.22 Chorioretinal inflammation (1/3/96) 791.9 Other nonspecific findings on examination of urine 363.61-363.63 Choroidal hemorrhage and rupture 791.7 Other cells and casts in urine 364.21-364.3 Iridocyclitis (1/3/96) 364.41 Hyphema BLOOD COUNTS 364.42 Rubeosis iridis 383.00-383.22 Mastoiditis (1/3/96) Medicare A Washington and Alaska 391.0-391.9 Rheumatic fever (1/3/96) Local Medical Review Policy February 1, 2000 392.0-392.9 Rheumatic chorea (1/3/96) 397.9 Rheumatic diseases of endocardium (1/3/96) CPT: 85007-85031 398.0 Rheumatic myocarditis (1/3/96) CPT: 85048 398.90 Rheumatic heart disease, unspecified (1/3/96) 401.0-401.9 Hypertension 001.0-136.9 Infectious and parasitic diseases 402.00-402.91 Hypertensive heart disease 141.0-141.9 Malignant neoplasm of tongue 420.0-420.99 Pericarditis 142.0-142.9 Malignant neoplasm of salivary glands 421.0-421.9 Endocarditis 144.0-144.9 Malignant neoplasm of floor of mouth 422.0-422.99 Acute myocarditis (1/3/96) 145.0-145.9 Malignant neoplasm of other and unspecified parts of mouth 424.90 Endocarditis, valve unspecified (1/3/96) 146.0-146.9 Malignant neoplasm of oropharynx 424.91 Endocarditis in diseases classified elsewhere (1/3/96) 147.0-147.9 Malignant neoplasm of nasopharynx 428.0-428.9 Heart failure 148.0-148.9 Malignant neoplasm of hypopharynx 430-437.9 Cerebrovascular disease (4/22/96) 149.0-149.9 Malignant neoplasm of other and ill-defined sites within lip, oral cavity and 446.20 Hypersensitivity angiltis (1/3/96) pharynx 446.21 Goodpasture’s syndrome (1/3/96) 150.0-159.9 Malignant neoplasms, digestive organs, and peritoneum 446.29 Other hypersensitivity angiitis (1/3/96) 160.0-160.9 Malignant neoplasms nasal cavities, middle ear and accessory sinuses (1/3/96) 446.6 Thrombotic microangiopathy 161.0-161.9 Malignant neoplasm of larynx (1/3/96) 458.0-458.9 Hypotension (1/22/96) 162.0-163.9 Malignant neoplasms, trachea lung, pleura, bronchus 461.0-461.9 Acute sinusitis (1/3/96) 164.0-164.9 Malignant neoplasms of thymus, heart, and mediastinum (1/3/96) 462 Acute pharyngitis 165.0-165.9 Malignant neoplasms of other and ill-defined sites within the respiratory system 463 Acute tonsillitis and intrathoracic organs 464.0-464.4 Acute laryngitis and tracheitis 170.0-171.9 Malignant neoplasms of bone, cartilage, other connective and soft tissue (1/3/ 465.0-465.9 Acute upper respiratory infection of multiple or unspecified sites 96) 466.0-466.1 Acute bronchitis (1/3/96) 172.0-172.9 Malignant melanoma of skin 477.0-477.9 Allergic rhinitis (1/3/96) 173.0-173.9 Other malignant neoplasm of skin (1/3/96) 478.8-478.9 Upper respiratory tract hypersensitivity reaction (1/3/96) 174.0-175.9 Malignant neoplasm, breast 480.0-487.8 Pneumonia and Influenza 176.0-176.9 Kaposi’s sarcoma 493.00-493.91 Asthma (1/3/96) 179-189.9 Malignant neoplasm, genito-urinary 495.0-495.9 Extrinsic allergic alveolitis (1/3/96) 190.0-199.1 Malignant neoplasm of other and unspecified sites (1/3/96) 510.0-510.9 Empyema (1/3/96) 200.00-208.91 Malignant neoplasm, lymphatic and hematopoietic including leukemias 511.1 Pleurisy with effusion (1/3/96) 233.0-233.9 Carcinoma in situ, breast, genito-urinary 513.0-513.1 Abscess of lungs (1/3/96) 235.2-235.5 Neoplasm, uncertain behavior, digestive system 518.3 Pulmionary eosinophilia (1/3/96) 236.0-236.99 Neoplasm, uncertain behavior, genito-urinary 527.3 Abcess salivary gland (1/3/96) 238.4-238.7 Polycythemia vera; Neoplasm, uncertain behavior of histiocytic and mast cells, 528.3 Cellulitis/abcess salivary gland (1/3/96) plasma cells and other lymphatic and hematopoietic tissues 528.5 Cellulitis lips (1/3/96) 261-263.9 Nutritional deficiencies 533.00-535.61 Peptic ulcer, gastrojejunal ulcer, gastritis, duodenitis 266.2 Other B-complex deficiencies (1/3/96) 537.82-537.83 Angiodysplasia of the stomach 273.0-273.1 Disorders of protein metabolism (1/3/96) 540.0-540.9 Acute appendicitis (1/3/96) 273.2 Other paraproteinemias (4/22/96) 555.0-558.9 Regional enteritis and ulcerative colitis, vascular insufficiency of intestine, 273.3 Waldenstrom’s macroglobulinemia gastroenteritis and colitis (radiation, toxic) 273.9 Unspecified disorder of plasma protein metabolism 562.00-562.13 Diverticulosis and diverticulitis of the small intestines and colon 275.0 Disorders of Iron metabolism (hemochromatosis) (1/15/96) 564.9 Unpsecified functional disorder of intestine (1/2/96)

SEPTEMBER 2000 73 LMRPs WASHINGTON A (509) 927-6250 • 1-800-433-1583

566 Abscess of anal and rectal region 780.71-780.79 Malaise and fatigue 567.0-567.9 Peritonitis 782.61 Pallor 569.5 Abscess intestine (1/3/96) 782.7 Spontaneous ecchymoses 569.82-569.85 Ulceration, perforation, angiodysplasia of the intestine 783.2 Abnormal weight loss 574.00-575.4 Cholelithiasis, cholecystitis and other disorders of gallbladder 784.0 Headache 576.1 Cholangitis 785.50-785.59 Shock without mention of trauma (1/22/96) 577.0 Acute pancreatitis 789.00-789.09 Abdominal pain 578.0-578.9 G-I hemorrhage, including hemtemesis and melena 790.0 Abnormality of the red blood cells 580.0-589.9 Nephritis, nephrotic syndrome, nephrosis 792.1 Non-specific abnormal findings in stool (occult blood) 590.00-590.81 Infection of kidney 806.00-806.9 Fracture of vertebral column with spinal cord injury 592.0-592.9 Urinary calculus 808.0-808.9 Fracture of pelvis 593.81 Vascular disorders of kidney (hemorrhage, thrombosis, etc) 820.00-821.39 Fracture of femur 593.9 Unspecified disorder of kedney and ureter (4/22/96) 860.0-869.1 Internal injury thorax, abdomen, pelvis 599.7 Hemorrhage of rectum and anus 900.00-901.9 Injury to blood vessels 601.2 Abscess of prostate 921.3 Contusion of eyeball 602.1 Hemorrhage prostate 942.00-942.59 Burn of trunk (1/3/96) 604.0-604.91 Orchitis, epidiymitis 958.2-958.3 Secondary/recurrent hemorrhage; Post traumatic wound infection (1/3/96) 608.0 Seminal vesiculitis (abscess) 958.4 Traumatic shock (1/22/96) 608.4 Other inflammatory diseases of the male genital organs 960.0-960.9 Poisoning by antibiotics (1/3/96) 608.83 Vascular disorders of the male genital organs 963.1 Poisoning by antineoplastics and Immunosuppressives (1/3/96) 611.0 Inflammatory disease of the breast (abcess) 965.5-965.9 Poisoning by analgesics (1/3/96) 614.0-616.0 Inflammatory disease of female pelvic organs 967.0 Poisoning by barbiturates (1/3/96) 616.3-616.4 Bartholin abscess, other abscesses of vulva 969.1 Poisoning by tranquilizers (1/3/96) 619.0 Urinary genital tract fistula (1/3/96) 969.4-969.5 Poisoning by tranquilizers (1/3/96) 626.0-627.1 Disorders of menstruation; other abnormal bleeding from the female genital tract 982.2 Toxic effects of carbon disulfide (1/3/96) 633.0-633.9 Ectopic pregnancy 985.0-985.1 Toxic effects of mercury and arsenic (1/3/96) 634.00-634.12 985.4 Toxic effects of antimony (1/3/96) 634.50-634.52 Spontaneous abortion with infection, hemorrhage; shock 989.5 Toxic effects of venom (snakebite) 635.50-635.52 Legal induced aboriton with infection, hemorrhage; shock 996.60-996.69 Infection due to internal prosthetic device, Implant or graft 636.00-636.02 Illegally induced abortion with infection (1/3/96) 998.51-998.59 Postoperative infection (5th digit added 1/97) 637.50-637.52 Unspecified abortion with infection, hemorrhage; shock 999.3 Other infection (1/3/96) 638.5 Failed attempted abortion with infection, hemorrhage; shock V12.3 Personal history of disease of the blood and blood-forming organs 639.0-639.1 V58.0 Radiotherapy 639.5 Complications following abortion, ectopic and molar pregnancies V58.1 Chemotherapy 640.00-640.93 Hemorrhage in early pregnancy (note: 2 is not a valid 5th digit) V58.69 Long term (current) use of other (high risk) medications (1/1/96) 641.00-641.93 Antepartum hemorrhage (note: 2 is not a valid 5th digit) V67.0-V67.2 Follow-up exam following surgery, radiotherapy or chemotherapy 646.60-646.64 Infections of GU tract in pregnancy (1/3/96) V67.51 Follow-up of high risk medication 647.00-647.94 Infections complicationg pregnancy V71.1 Observation for suspected malignant neoplasm 648.20-648.24 Anemia in pregnancy V72.83 Other specified pre-operative examination. (This ICD-9 code may be used when a 658.40-658.43 Infection of amniotic cavity medically necessary blood count is performed prior to major sugery where 666.00-667.14 Postpartum hemorrhage, coagulation defects and retained portion of placenta or signifigant blood loss is possible. The medical necesity must be documented in membranes the patient’s record 669.10-669.14 Shock during or following labor and delivery 670.0-670.04 Major puerperal infection 672.0-672.04 Pyrexia of unknown origin during puerperium 674.30-674.34 Comlications of OB surgical wound (1/3/96) 675.00-675.14 675.80-675.94 Infection of breast associated with childbirth 681.00-682.9 Cellulitis and abscess 698.2 Prurigo 710.0-710.9 Diffuse diseases of connective tissue 711.00-711.49 Arthropathy associated with infection 711.90-711.99 Unspecified infectious arthritis 713.2 Arthropathy associated with hematological disorders 714.0-714.9 Rheumatoid arthritis and other inflammatory polyarthropathies 719.40-719.49 Pain in joint 720.0-720.9 Ankylosing spondylitis and other inflammatory spondylopathies 730.00-730.29 Osteomyelitis 753.10-753.19 Cystic kidney disease 759.0 Anomalies of spleen 760.1 Maternal renal urinary tract diseases (1/3/96) 773.0-773.1 Hemolytic diseases of fetus or newborn due to isoimmunization (1/3/96) 780.01-780.09 Alteration of consciousness 780.1 Hallucinations 780.2 Syncope & Collapse 780.31-780.39 Convulsions 780.6 Pyrexia

74 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON A

GAMMA GLUTAMYLTRANSFERASE (GGT) PARTIAL THROMBOPLASTIN TIME Medicare A Premera Blue Cross Medicare A Premera Blue Cross Local Medical Review Policy March 31, 1998 Local Medical Review Policy March 31, 1998

CPT: 82977 CPT: 85370

017.90-017.96 Tuberculosis of other specified organs, confirmation unspecified 286.0 Congenital factor VIII disorder - Hemophilia A 070.0-070.9 Viral hepatitis 286.1 Congenital factor IX disorder - Hemophilia B 072.71 Mumps hepatitis 286.2-286.3 Other congenital factor deficiencies 074.8 Other specified diseases due to Coxsackie virus 286.4 von Willebrand’s disease 075 Infectious mononucleosis 286.5 Hemorrhagic disorder due to circulating anticoagulants 078.5 Cytomegaloviral disease 286.6 Defibrination syndrome 084.9 Other pernicious complications of malaria 286.7 Acquired coagulation factor deficiency 130.5 Hepatitis due to toxoplasmosis 287.9 Unspecified hemorrhagic conditions 153.0-153.9 Malignant neoplasm of colon 570 Acute and subacute necrosis of liver 154.0 Malignant neoplasm of rectosigmoid junction 154.1 Malignant neoplasm of rectum 154.8 Malignant neoplasm of other sites PLATELET COUNTS 155.0 Malignant neoplasm of liver, primary Medicare A Premera Blue Cross 155.2 Malignant neoplasm of liver, not specified as primary or secondary Local Medical Review Policy March 31, 1998 157.0-157.9 Malignant neoplasm of pancreas 174.0-174.9 Malignant neoplasm of female breast CPT: 85585 Platelet; estimation on smear, only 175.0-175.9 Malignant neoplasm of male breast CPT: 85590 Platelet count, manual 186.9 Malignant neoplasm of other and unspecified testis CPT: 85595 Platelet count, automated 197.5 Secondary malignant neoplasm of large intestine and rectum 197.7 Secondary malignant neoplasm of liver, specified as secondary 200.00-200.88 Lymphosarcomas and lymphomas 197.8 Secondary malignant neoplasm of other digestive organs and spleen 201.0-201.9 Hodgkin’s disease 198.81 Secondary malignant neoplasm of breast 202.0-202.9 Other lymphomas 211.5 Benign neoplasm of liver and biliary passages 203.00-203.81 Multiple Myeloma and immunoproliferative neoplasms 211.6 Benign neoplasm of pancreas, except islets of Langerhans 204.00-204.91 Lymphoid leukemia 230.3 Carcinoma in situ of colon 205.00-208.91 Myeloid, Monocytic, Other Monocytic Leukemia 230.8 Carcinoma in situ of liver and biliary system 207.2 Megakaryocytic leukemia 230.9 Carcinoma in situ of other and unspecified digestive organs 238.4 Polycythemia vera 235.2 Neoplasm of uncertain behavior of stomach, intestines, and rectum 238.7 Idiopathic thrombocythemia, Myelodyplastic syndrome, etc 235.3 Neoplasm of uncertain behavior of liver and biliary passages 266.2 Deficiency of B complex components, other 235.5 Neoplasm of uncertain behavior of other and unspecified digestive organs 280.0 Iron deficiency anemia secondary to blood loss (chronic) 238.3 Neoplasm of uncertain behavior of breast 280.8 Other specified iron deficiency anemias 239.0 Neoplasm of unspecified nature of digestive system 281.2 Floate-deficiency anemia 275.0 Disorders of iron metabolism 281.3 Other specified megaloblastic anemias not elsewhere classified 275.1 Disorders of copper metabolism 281.9 Unspecified deficiency anemia 277.00 Cystic fibrosis without mention of meconium ileus 282.2 Anemia due to disorders of glutathione metabolism 291.0 Alcohol withdrawal dementia 284.0 Constitutional aplastic anemia 291.1 Alcohol anmestic syndrome 284.8 Other specified aplastic anemias 291.2 Other alcohol dementia 284.9 Aplastic anemia, unspecified 291.3 Alcohol withdrawal hallucinosis 285.1 Acute posthemorrhagic anemia 291.4 Idiosyncratic alcohol intoxication 286.6 Defibrination syndrome 291.5 Alcoholic jealousy, paranoia, psychosis 286.9 Other and unspecified coagulation defects 303.00-303.03 Acute alcoholic intoxication 287.0-287.9 Purpura and other hemorrhagic conditions 303.90-303.93 Other and unspecified alcohol dependence 289.0 Polycythemia, secondary 305.00-305.92 Nondependent abuse of drugs 289.6 Familial polycythemia 570 Acute and subacute necrosis of liver 289.9 Unspecified diseases of blood and blood-forming organs 571.0-571.9 Chronic liver disease and cirrhosis 446.6 Thrombotic microangiopathy 572.0-572.8 Liver abscess and sequelae of chronic liver disease 666.34 Postpartum coagulation defects, postpartum condition or complication 573.0-573.9 Other disorders of liver 719.10-719.19 Hemarthrosis 574.00-574.51 Cholelithiasis 759.0 Anomalies of spleen 575.0-575.9 Other disorders of gallbladder 776.1 Transient neonatal thrombocytopenia 576.0-576.9 Other disorders of biliary tract 776.4 Polycythemia neonatorum 577.0-577.9 Diseases of pancreas 782.7 Spontaneous ecchymoses (petachiae) 774.4 Perinatal jaundice due to hepatocellular damage 789.2 Splenomegaly 789.1 Heptomegaly V45.89 Other post surgical status [splenectomy] V11.3 Personal history of alcoholism V58.61 Long term (current) use of anticoagulants V42.7 Liver replaced by transplant V58.69 Long term (current) use of high risk medications V58.69 Long-term (current) use of other medications V67.1 Follow up exam following radiotherapy V67.2 Follow up exam following chemotherapy V67.51 Follow up exam following completed treatment with high risk medication (NOC)

SEPTEMBER 2000 75 LMRPs WASHINGTON A (509) 927-6250 • 1-800-433-1583

PROSTATE SPECIFIC ANTIGEN (PSA) 413.0-413.9 Angina pectoris 414.05 Coronary atherosclerosis Medicare A Premera Blue Cross 414.8 Other specified forms of chronic ischemic heart disease Local Medical Review Policy November 11/15/96 414.9 Chronic ischemic hear disease, unspecified 415.0-415.19 Acute pulmonary heart disease CPT: 84153 416.9 Chronic pulmonary heart disease, unspecified 424.0 Mitral valve disorders 170.2 Malignant neoplasm of vertebral column, excluding sacrum and coccyx 425.0-425.9 Cardiomyopathy 185 Malignant neoplasm of the prostate 427.0-427.9 Cardiac dysrhythmias 188.5 Malignant neoplasm of bladder neck 428.0-428.9 Heart failure 188.8 Malignant neoplasm of other specified sites of bladder 429.0-429.4 Ill-defined descriptions and complications of heart disease 196.5 Secondary and unspecified malignant neoplasm of lymph nodes and unguinal 429.79 Other certain sequelae of myocardial infarction, not elsewhere classified region and lower limb 432.0-432.9 Other and unspecified intracranial hemorrhage 196.6 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes 433.00-433.91 Occlusion and stenosis of precerebral arteries 196.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple sites 434.00-434.91 Occlusion of cerebral arteries 198.5 Secondary malignant neoplasm, bone and bone marrow 435.0-435.9 Transient cerebral ischemia 198.82 Secondary malignant neoplasm, genital organs 436 Acute, but ill-defined cerebrovascular disease 233.4 Carcinoma in situ, prostate 437.0 Cerebral atherosclerosis 236.5 Neoplasm of uncertain behavior, prostate 437.1 Other generalized ischemic cerebrovascular disease 239.5 Neoplasm of unspecified nature, other enitourinary organs 437.6 Nonpyogenic thrombosis of intracranial venous sinus 600 Hyperplasia of the prostate 440.0-440.9 Atherosclerosis 790.93 Elevated prostate specific antigen (PSA) 443.0-443.9 Other peripheral vascular disease V10.46 Personal history of malignant neoplasm, prostate 444.0-444.9 Arterial embolism and thrombosis V71.1 Observation for suspected malignant neoplasm 447.1 Stricture of artery 451.0-451.9 Phlebitis and thrombophlebitis of intracranial venous sinuses PROSTATIC ACID PHOSPHATASE (PAP) 452 Portal vein thrombosis 453.0-453.9 Other venous embolism and thrombosis Medicare A Premera Blue Cross 459.0 Hemorrhage, unspecified Local Medical Review Policy March 31, 1998 459.1 Postphlebitis syndrome 459.2 Compression of vein CPT: 84066 Phosphatase, acid; prostatic 459.81 Venous (peripheral) insufficiency, unspecified 514 Pulmonary congestion and hypostasis 185 Malignant neoplasm of prostate 569.3 Hemorrhage of rectum and anus 198.5 Secondary malignant neoplasm of bone and one marrow 571.0-571.9 Chronic liver disease and cirrhosis 222.2 Benign neoplasm of prostate 572.2 Hepatic coma 233.4 Carcinoma in situ; prostate 572.4 Hepatorenal syndrome 236.5 Neoplasm of uncertain behavior; prostate 572.8 Other sequelae of chronic liver disease 239.5 Neoplasms of unspecified nature; other genitourinary organs 573.9 Unspecified disorder of liver 790.93 Elevated prostate specific antigen (PSA) 577.0 Acute pancreatitis V10.46 Personal history of malignant neoplasm; prostate 578.0-578.9 Gastrointestinal hemorrhage 579.2 Blind loop syndrome 599.7 Hematuria PROTHROMBIN TIME (PT) 671.20-671.54 Venous complications in pregnancy and the puerperium Medicare A Premera Blue Cross 671.90-671.94 Unspecified venous complication Local Medical Review Policy March 31, 1998 673.00-673.84 Obstetrical pulmonary embolism 719.15 Hemarthrosis (5th digits 5,6, and 9 allowed only) CPT: 85610 746.00-746.9 Congenital anomalies of heart 782.7 Spontaneous ecchymosis 070.0-070.9 Viral hepatitis 784.7 Epistaxis 269.0 Deficiency of Vitamin K 784.8 Hemorrhage form throat 285.1 Acute posthemorrhagic anemia 786.3 Hemoptysis 286.0-286.9 Coagulation defects 789.1 Hepatomegaly 287.0-287.9 Purpura and other hemorrhagic conditions 789.5 Ascites 290.40-290.43 Arteriosclerotic dementia 790.92 Abnormal coagulation profile 325 Phlebitis and thrombophlebitis of intracranial venous sinuses 852.00-852.59 Subarachnoid, subdural, and extradural hemorrhage 362.30-362.37 Retinal vascular occlusion 964.2 Poisoning by anticoagulant 386.2 Vertigo of central origin 995.2 Unspecified adverse effect of drug, medical and biological substance (due to 386.50 Labyrinthine dysfunction, unspecified correct medical substance properly administered). 394.0-394.9 Diseases of the mitral valve V12.3 Personal history of diseases of blood and blood-forming organs 395.0 Rheumatic aortic stenosis V15.1 Personal history of surgery to heart and great vessels 395.2 Rheumatic aortic stenosis with insufficiency V42.2 Heart valve replaced by transplant 396.0-396.9 Diseases of mitral and aortic valves V42.7 Liver replaced by transplant 410.00-410.92 Acute myocardial infarction V43.2 Heart replaced by other means 411.1 Intermediate coronary syndrome V43.3 Heart valve replaced by other means 411.81 Coronary occlusion without myocardial infarction V43.4 Blood vessel replaced by other means 411.89 Other acute and subacute forms of ischemic heart disease V43.60 Unspecified joint replaced by other means V58.61 Long-term (current ) use of anticoagulants

76 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON A

RETICULOCYTE COUNTS 098.80-098.89 Gonococcal infections 099.0-099.9 Other venereal diseases Medicare A Premera Blue Cross 104.0 Nonvenereal endemic syphilis Local Medical Review Policy March 31, 1998 131.00-131.9 Trichomoniasis 331.0 Alzheimer’s disease CPT: 85044 Blood count; reticulocyte count, manual 331.2 Senile degeneration of brain CPT: 85045 Blood count; reticulocyte count, flow cytometry 356.0 Hereditary peripheral neuropathy 356.9 Unspecified hereditary and idiopathic peripheral neuropathy 280.0-285.9 Anemias 364.00 Acute and subacute iridocyclitis, unspecified 614.0-614.9 Inflammatory disease of ovary, fallopian tube, pelvic organs and tissues RHEUMATOID FACTOR TEST 615.0-615.9 Inflammatory diseases of uterus, except cervix 616.0-616.9 Inflammatory disease of cervix, vagina, and valva Medicare A Premera Blue Cross 713.5 Arthropathy associated with neurological disorders (i.e., Charcot’s arthropathy) Local Medical Review Policy March 31, 1998 760.2 Maternal infection V01.6 Contact with or exposure to venereal diseases CPT: 86430 Rheumatoid factor test; qualitative CPT: 86431 quantitative

015.00-015.26 Tuberculosis of bones and joints 015.80-015.96 Tuberculosis of bones and joints 030.9 Leprosy, unspecified 075 Infectious mononucleosis 095.8 Other specified forms of late symptomatic syphilis 135 Sarcoidosis 273.2 Other paraproteinemias 274.0 Gouty arthropathy 421.9 Acute endocarditis, unspecified 446.5 Giant cell arteritis 516.3 Idiopathic fibrosing alveolitis 571.9 Unspecified chronic liver disease without mention of alcohol 701.0 Circumscribed scleroderma 710.0-710.4 Diffuse diseases of connective tissue 710.9 Unspecified diffuse connective tissue disease 711.10-711.19 Arthropathy associated with infections 711.20-711.29 Arthropathy associated with infections 711.30-711.39 Arthropathy associated with infections 712.10-712.39 Crystal arthropathies 712.80-712.99 Other Specified Crystal Arthropathies, Site Unspecified 713.0-713.6 Arthropathy associated with other disorders classified elsewhere 714.0-714.2 Rheumatoid arthritis and other inflammatory polyarthropathies 714.30-714.33 Juvenile chronic polyarthritis 714.4 Chronic postrheumatic arthropathy 714.81 Rheumatoid lung 714.89 Other specified inflammatory polyarthropathies 714.9 Unspecified inflammatory polyarthropathy 725 Polymyalgia rheumatica SYPHILIS TEST Medicare A Premera Blue Cross Local Medical Review Policy March 31, 1998

CPT: 86592 Syphilis test; qualitative (eg, VDRL, RPR, ART) CPT: 86593 quantitative CPT: 86781 Treponema Pallidum, confirmatory test (eg, FTA-abs)

042 Human immunodeficiency virus (HIV) disease 054.10-054.19 Herpes simplex, genital herpes 078.0-078.19 Other diseases due to viruses and chlamydia 090.0-090.9 Congenital syphilis 091.0-091.9 Early syphilis symptomatic 092.0-092.9 Early syphilis, latent 093.0-093.9 Cardiovascular syphilis 094.0-094.9 Neurosyphilis 095.0-095.9 Other forms of late syphilis, with symptoms 096 Late syphilis, latent 097.0-097.9 Other and unspecified syphilis

SEPTEMBER 2000 77 LMRPs WASHINGTON A (509) 927-6250 • 1-800-433-1583

78 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON B

LMRPs Washington Medicare B

SEPTEMBER 2000 79 LMRPs WASHINGTON B (509) 927-6250 • 1-800-433-1583 LMRPs – Washington Medicare B

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80 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON B

BACTERIAL CULTURE, URINE blood and blood forming organs 294.0-294.9 Other organic psychotic conditions (chronic) (5/1/96) Medicare B Medical Policy May 1, 1999 295.00-295.95 Schizophrenic disorders (5/1/96) 296.20-296.25 Major depressive disorder, single episode (5/1/96) CPT: 87086 Culture, bacterial, urine quantitative, colony count 296.30-296.35 Major depressive disorder, recurrent episode (5/1/96) CPT: 87087 commercial kit 296.7 Bipolar affective disorder, unspecified (5/1/96) CPT: 87088 Identification, in addition to quantitative or commercial kit 298.8 Other and unspecified reactive psychosis (5/1/96) 300.00-300.01 Anxiety states (5/1/96) 038.0-038.9 Streptococcal septicemia 307.1 Anorexia nervosa (5/1/96) 580.0-589.9 Acute glomerulonephritis with lesion of proliferative glomerulonephritis 307.50 Eating disorder (5/1/96) 590.00-599.9 Chronic pyelonephritis 307.51 Bulimia (5/1/96) 600-608.9 Hyperplasia of prostate 320.0-325 Inflammatory diseases of central nervous system 625.6 Stress incontinence, female 326 Late affects, intracranial abscess or pyogenic infection (1/3/96) 646.5 Asymptomatic bacteriuria in pregnancy 360.00-360.19 Endophthalmitis (1/3/96) 780.6 Fever 362.30-362.37 Retinal vascular occlusion 788.0-788.9 Renal Colic 363.00-363.22 Chorioretinal inflammation (1/3/96) 790.7 Bacteremia 363.61-363.63 Choroidal hemorrhage and rupture 791.0-791.7 Proteinuria 364.21-364.3 Iridocyclitis (1/3/96) 791.9 Other nonspecific findings on examination of urine 364.41 Hyphema 364.42 Rubeosis iridis 383.00-383.22 Mastoiditis (1/3/96) BLOOD COUNTS 391.0-391.9 Rheumatic fever (1/3/96) Medicare B Medical Policy August 1, 1999 392.0-392.9 Rheumatic chorea (1/3/96) 397.9 Rheumatic diseases of endocardium (1/3/96) CPT: 85007-85031 398.0 Rheumatic myocarditis (1/3/96) CPT: 85048 398.90 Rheumatic heart disease, unspecified (1/3/96) 401.0-401.9 Hypertension 001.0-136.9 Infectious and parasitic diseases 402.00-402.91 Hypertensive heart disease 141.0-141.9 Malignant neoplasm of tongue 420.0-420.99 Pericarditis 142.0-142.9 Malignant neoplasm of salivary glands 421.0-421.9 Endocarditis 144.0-144.9 Malignant neoplasm of floor of mouth 422.0-422.99 Acute myocarditis (1/3/96) 145.0-145.9 Malignant neoplasm of other and unspecified parts of mouth 424.90 Endocarditis, valve unspecified (1/3/96) 146.0-146.9 Malignant neoplasm of oropharynx 424.91 Endocarditis in diseases classified elsewhere (1/3/96) 147.0-147.9 Malignant neoplasm of nasopharynx 428.0-428.9 Heart failure 148.0-148.9 Malignant neoplasm of hypopharynx 430-437.9 Cerebrovascular disease (4/22/96) 149.0-149.9 Malignant neoplasm of other and ill-defined sites within lip, oral cavity and 446.20 Hypersensitivity angiltis (1/3/96) pharynx 446.21 Goodpasture’s syndrome (1/3/96) 150.0-159.9 Malignant neoplasms, digestive organs, and peritoneum 446.29 Other hypersensitivity angiitis (1/3/96) 160.0-160.9 Malignant neoplasms nasal cavities, middle ear and accessory sinuses (1/3/96) 446.6 Thrombotic microangiopathy 161.0-161.9 Malignant neoplasm of larynx (1/3/96) 458.0-458.9 Hypotension (1/22/96) 162.0-163.9 Malignant neoplasms, trachea lung, pleura, bronchus 460 Acute nasopharyngitis 164.0-164.9 Malignant neoplasms of thymus, heart, and mediastinum (1/3/96) 461.0-461.9 Acute sinusitis (1/3/96) 165.0-165.9 Malignant neoplasms of other and ill-defined sites within the respiratory system 462 Acute pharyngitis and intrathoracic organs 463 Acute tonsillitis 170.0-171.9 Malignant neoplasms of bone, cartilage, other connective and soft tissue (1/3/ 464.0-464.4 Acute laryngitis and tracheitis 96) 465.0-465.9 Acute upper respiratory infection of multiple or unspecified sites 172.0-172.9 Malignant melanoma of skin 466.0-466.19 Acute bronchitis (1/3/96) 173.0-173.9 Other malignant neoplasm of skin (1/3/96) 477.0-477.9 Allergic rhinitis (1/3/96) 174.0-175.9 Malignant neoplasm, breast 478.8-478.9 Upper respiratory tract hypersensitivity reactive (1/3/96) 176.0-176.9 Kaposi’s sarcoma 480.0-487.8 Pneumonia and Influenza 179-189.9 Malignant neoplasm, genito-urinary 493.00-493.91 Asthma (1/3/96) 190.0-199.1 Malignant neoplasm of other and unspecified sites (1/3/96) 495.0-495.9 Extrinsic allergic alveolitis (1/3/96) 200.00-208.91 Malignant neoplasm, lymphatic and hematopoietic including leukemias 510.0-510.9 Empyema (1/3/96) 233.0-233.9 Carcinoma in situ, breast, genito-urinary 511.1 Pleurisy with effusion (1/3/96) 235.2-235.5 Neoplasm, uncertain behavior, digestive system 513.0-513.1 Abscess of lung (1/3/96) 236.0-236.99 Neoplasm, uncertain behavior, genito-urinary 518.3 Pulmionary eosinophilia (1/3/96) 238.4-238.7 Polycythemia vera; Neoplasm, uncertain behavior of histiocytic and mast cells, 527.3 Abcess salivary gland (1/3/96) plasma cells and other lymphatic and hematopoietic tissues 528.3 Cellulitis/abcess oral tissue (1/3/96) 261-263.9 Nutritional deficiencies 528.5 Cellulitis lips (1/3/96) 266.2 Other B-complex deficiencies (1/3/96) 533.00-535.61 Peptic ulcer, gastrojejunal ulcer, gastritis, duodenitis 273.0-273.1 Disorders of protein metabolism (1/3/96) 537.82-537.83 Angiodysplasia of the stomach 273.2 Other paraproteinemias (4/22/96) 540.0-540.9 Acute appendicitis (1/3/96) 273.3 Waldenstrom’s macroglobulinemia 555.0-558.9 Regional enteritis and ulcerative colitis, vascular insufficiency of intestine, 273.9 Unspecified disorder of plasma protein metabolism gastroenteritis and colitis (radiation, toxic) 275.0 Disorders of Iron metabolism (hemochromatosis) (1/15/96) 562.00-562.13 Diverticulosis and diverticulitis of the small intestines and colon 280.0-285.9 Anemias 564.9 Unpsecified functional disorder of intestine (1/2/96) 286.0-289.9 Coagulation defects, purpura, diseases of white blood cells, other diseases of 566 Abscess of anal and rectal region

SEPTEMBER 2000 81 LMRPs WASHINGTON B (509) 927-6250 • 1-800-433-1583

567.0-567.9 Peritonitis 780.31-780.39 Convulsions 569.5 Abscess intestine (1/3/96) 780.6 Pyrexia 569.82-569.85 Ulceration, perforation, angiodysplasia of the intestine 780.71-780.79 Malaise and fatigue 574.00-575.4 Cholelithiasis, cholecystitis and other disorders of gallbladder 782.61 Pallor 576.1 Cholangitis 782.7 Spontaneous ecchymoses 577.0 Acute pancreatitis 783.2 Abnormal weight loss 578.0-578.9 G-I hemorrhage, including hemtemesis and melena 784.0 Headache 580.0-589.9 Nephritis, nephrotic syndrome, nephrosis 785.50-785.59 Shock without mention of trauma (1/22/96) 590.00-590.81 Infection of kidney 786.50-786.59 Chest pain 592.0-592.9 Urinary calculus 789.00-789.09 Abdominal pain 593.81 Vascular disorders of kidney (hemorrhage, thrombosis, etc) 790.0 Abnormality of the red blood cells 593.9 Unspecified disorder of kidney and water (4/22/96) 792.1 Non-specific abnormal findings in stool (occult blood) 599.7 Hematuria 806.00-806.9 Fracture of vertebral column with spinal cord injury 601.2 Abscess of prostate 808.0-808.9 Fracture of pelvis 602.1 Hemorrhage of prostate 820.00-821.39 Fracture of femur 604.0-604.91 Orchitis, epidiymitis 860.0-869.1 Internal injury thorax, abdomen, pelvis 608.0 Seminal vesiculitis (abscess) 900.00-901.9 Injury to blood vessels 608.4 Other inflammatory disease of the male genital organs 921.3 Contusion of eyeball 608.83 Vascular disorders of the male genital organs 942.00-942.59 Burn of trunk (1/3/96) 611.0 Inflammatory disease of the breast (abcess) 958.2-958.3 Secondary/recurrent hemorrhage; Post traumatic wound infection (1/3/96) 614.0-616.0 Inflammatory disease of female pelvic organs 958.4 Traumatic shock (1/22/96) 616.3-616.4 Bartholin abscess, other abscesses of vulva 960.0-960.9 Poisoning by antibiotics (1/3/96) 619.0 Urinary genital tract fistula (1/3/96) 963.1 Poisoning by antineoplastics and Immunosuppressive (1/3/96) 626.0-627.1 Disorders of menstruation; other abnormal bleeding from the female genital tract 965.5-965.9 Poisoning by analgesics (1/3/96) 633.0-633.9 Ectopic pregnancy 967.0 Poisoning by barbiturates (1/3/96) 634.00-634.12, 969.1 Poisoning by tranquilizers (1/3/96) 634.50-634.52 Spontaneous abortion with infection, hemorrhage; shock 969.4-969.5 Poisoning by tranquilizers (1/3/96) 635.00-635.12, 982.2 Toxic effects of carbon disulfide (1/3/96) 635.50-635.52 Legal induced abortion with infection, hemorrhage; shock 985.0-995.1 Toxic effects of mercury and arsenic (1/3/96) 636.00-636.02 Illegally induced abortion with infection (1/3/96) 985.4 Toxic effects of antimony (1/3/96) 637.00-637.12, 989.5 Toxic effects of venom (snakebite) 637.50-637.52 Unspecified abortion with infection, hemorrhage; shock 996.60-996.69 Infection due to internal prosthetic device, Implant or graft 638.0-638.1, 998.51-998.59 Postoperative infection (5th digit added 1/97) 638.5 Failed attempted abortion with infection, hemorrhage; shock 999.3 Other infection (1/3/96) 639.0-639.1, V12.3 Personal history of disease of the blood and blood-forming organs 639.5 Complications following abortion, ectopic and molar pregnancies V58.0 Radiotherapy 640.00-640.93 Hemorrhage in early pregnancy (note: 2 is not a valid 5th digit) V58.1 Chemotherapy 641.00-641.93 Antepartum hemorrhage (note: 2 is not a valid 5th digit) V58.69 Long term (current) use of other (high risk) medications (1/1/96) 646.60-646.64 Infections of GU tract in pregnancy (1/3/96) V67.0-V67.2 Follow-up exam following surgery, radiotherapy or chemotherapy 647.00-647.94 Infections complicating pregnancy V67.51 Follow-up of high risk medication 648.20-648.24 Anemia in pregnancy V71.1 Observation for suspected malignant neoplasm 658.40-658.43 Infection of amniotic cavity V72.83 Other specified pre-operative examination. (This ICD-9 code may be used when a 666.00-667.14 Postpartum hemorrhage, coagulation defects and retained portion of placenta of medically necessary blood count is performed prior to surgery where significant membranes. blood loss is possible. The medical necessity must be documented in the 669.10-669.14 Shock during or following labor and delivery patient’s medical record.) 670.00-670.04 Major puerperal infection 672.00-672.04 Pyrexia of unknown origin during puerperium 674.30-674.34 Complications of OB surgical wound (1/3/96) 675.00-675.14, 675.80-675.94 Infection of breast associated with childbirth 681.00-682.9 Cellulitis and abscess 698.2 Prurigo 710.0-710.9 Diffuse diseases of connective tissue 711.00-711.49 Arthropathy associated with infection 711.90-711.99 Unspecified infectious arthritis 713.2 Arthropathy associated with hematological disorders 714.0-714.9 Rheumatoid arthritis and other inflammatory polyarthropathies 719.40-719.49 Pain in joint 720.0-720.9 Ankylosing spondylitis and other inflammatory spondylopathies 730.00-730.29 Osteomyelitis 753.10-753.19 Cystic kidney disease 759.0 Anomalies of spleen 760.1 Maternal renal urinary tract diseases (1/3/96) 773.0-773.1 Hemolytic diseases of fetus or newborn due to isoimmunization (1/3/96) 780.01-780.09 Alteration of consciousness 780.1 Hallucinations 780.2 Syncope & Collapse

82 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON B

GLUCOSE TESTING (BLOOD) BLOOD, OCCULT; FECES SCREENING Medicare B Medical Policy September 1995 Medicare B Medical Policy September 1995

CPT: 82947 CPT: 82270 CPT: 82948 CPT: 82962 006.0-006.9 Amebiasis (1/3/96) 008.41-008.8 Intestinal infections due to other organisms (1/3/96) 112.0-112.2 Candidiasis, mouth, vulva, vagina or other urogenital sites 009.0-009.3 Ill-defined intestinal infections 157-157.9 Malignant neoplasm of pancreas 022.2 Gastrointestinal anthrax (1/3/96) 194.0 Malignant neoplasm of adrenal gland 140-239.9 Neoplasms (Except 235.9) 198.7 Secondary malignant neoplasm of adrenal gland 280.0-289.9 Anemia (s), any and all types 211.6-211.7 Benign neoplasm of other parts of the digestive system; pancreas/Islets of 448.0 Hereditary hemorrhagic telangiectasia (1/3/96) Langerhans 455.0-455.8 Hemorrhoids 227.0 Benign neoplasm of adrenal gland 456.0-456.21 Esophageal varices 237.2 Neoplasm of uncertain behavior of adrenal gland 530.1-535.61 Diseases of esophagus, stomach 250.00-250.93 Diabetes mellitus 536.1-536.2 Acute dilation of stomach; persistent vomiting 251.0-251.9 Other disorders of pancreatic internal secretion 536.8-536.9 Disorders of function of stomach 252.0 Disorders of parathyroid gland; hyperparathyroidism 537.3-537.4 Obstruction of duodenum 253.0, 253.2, 537.82-537.83 Angiodysplasia of stomach and duodenum 253.7 Disorders of the pituitary gland and its hypothalamic control 537.89 Other disorders of the stomach and duodenum 255.0, 255.4 Disorders of adrenal glands 555-558.9 Non-infectious enteritis and colitis 279.9 Unspecified disorder of immune mechanism 560.30 Impaction of colon 356.9 Hereditary and idiopathic peripheral neuropathy; unspecified 560.39 Other impaction of intestine 357.2 Polyneuropathy in diabetes 562-562.13 Diverticula of intestine 357.8-357.9 Inflammatory and toxic neuropathy 564.0-564.9 Functional digestive disorders 360.30-360.34 Hypotony of eye 565.0-565.1 Anal fissure of anal fistula 362.0-362.18 Retinal disorders 569.0 Anal and Rectal polyp 362.81 Retinal hemorrhage 569.3 Hemorrhage of rectum and anus 365.0-365.00 Glaucoma suspect 569.41-569.42 Other specified disorders of rectum and anus 366.41 Diabetic cataract 569.84-569.85 Angiodysplasia of intestines 367.81-367.89 Other disorders of refraction and accomodation 577.0 Acute pancreatitis 570 Acute and sub-acute necrosis of liver 578.0-578.9 Gastrointestinal hemorrhage 571-571.9 Chronic liver disease and cirrhosis 579.0 Intestinal malabsorption (celiac disease) 572-572.8 Liver abscess and sequelae of chronic liver disease 579.8, 579.9 Specified or unspecified malabsorption 573-573.9 Other disorders of the liver 617.5 Endrometriosis of rectum 577.0-577.9 Diseases of pancreas 617.9 Endrometriosis of colon/bowel 648.00-648.04 Diabetes mellitus in pregnancy (1/3/96) 780.79 Malaise and fatigue 648.80-648.84 Abnormal glucose tolerance complicating the pregnant state 783.2 Abnormal loss of weight 695.89 Granuloma annulare 787.01-787.03 Nausea and vomiting 707.1 Ulcer of lower limbs, except decubitus 787.2 Dysphagia 780.0-780.09 General symptoms; alterations of consciousness 787.7 Abnormal feces 780.2 Syncope and collapse 787.99 Other symptons involving digestive system (change in bowel habits) 780.39 Convulsions 789.00-789.09 Abdominal pain 780.79 Malaise and fatigue 789.3-789.39 Abdominal or pelvic swelling mass or lump 781.0 Tremor 789.4-789.49 Abdominal rigidity 782.0 Symptoms involving skin and other integumentary tissue 789.5 Ascites 783.1-783.2 Abnormal weight gain/weight loss 789.6-789.69 Abdominal tenderness 783.5 Polydipsia 792.1 Nonspecific abnormal findings in stool contents 783.6 Polyphagia 794.8 Abnormal liver scan 785.0 Tachycardia V10.00-V10.09 Personal history of GI malignancy 788.4-788.42 Symptoms involving urinary system V12.72 Personal history of colonic polyps 790.2 Non-specific findings on examination of blood V58.61 Long term (current) use of anticoagulants (1/1/96) 790.6 Other abnormal blood chemistry V58.69 Long term (current) use of other medications (1/1/96) 791.5 Glycosuria V67.51 Following completed treatment with high risk medication, not elsewhere E932.0 E codes and V codes must be billed with the associated primary diagnosis. classified Drugs, medicinal and biological substance causing adverse effects in therapeutic use: Adrenal cortical steroids CARCINOEMBRYONIC ANTIGEN (CEA) V22-V22.2 Persons encountering health services in circumstances related to reproduction and development: Normal pregnancy Medicare B Medical Policy May 1, 1999 V23.0-V23.9 High risk pregnancy V58.69 Long term current use of other (high risk) medications (1/1/96) CPT: 82378 V67.51 Following treatment with high-risk medication, not elsewhere classified. 150.0-150.9 Malignant neoplasm of esophagus 151.0-151.9 Malignant neoplasm of stomach 152.0-152.9 Malignant neoplasm of small intestine, including duodenum 153.0-153.9 Malignant neoplasm of colon

SEPTEMBER 2000 83 LMRPs WASHINGTON B (509) 927-6250 • 1-800-433-1583

154.30-154.8 Malignant neoplasm of rectum, rectosigmoid junction, and anus 159.0 Malignant neoplasm of other ill-defined sites within the intestinal tract 162.0-162.9 Malignant neoplasm of trachea, bronchus, and lung 174.0-174.9 Malignant neoplasm of female breast 175.0-175.9 Malignant neoplasm of male breast 183.0 Malignant neoplasm of ovary 197.0 Secondary malignant neoplasm of lung 197.4 Secondary malignant neoplasm of small intestine 197.5 Secondary malignant neoplasm of large intestine and rectum 197.7 Secondary malignant neoplasm of liver 230.3 Carcinoma in situ of colon 230.4 Carcinoma in situ of rectum 230.7 Carcinoma in situ of other/unspecified parts of intestine 235.2 Neoplasm of uncertain behavior of stomach, intestines, rectum 555.0-555.9 Regional enteritis of intestines 556.0-556.9 Ulcerative colitis V10.00 Personal history of malignant neoplasm of gastrointestinal tract, unspecified V10.03 Personal history of malignant neoplasm, esophagus V10.05 Personal history of malignant neoplasm, large intestine V10.06 Personal history of malignant neoplasm, rectum, rectosigmoid junction, anus V10.11 Personal history of malignant neoplasm, bronchus, and lung V10.3 Personal history of malignant neoplasm, breast V10.43 Personal history of malignant neoplasm, ovary COLLAGEN CROSS LINKS (NTX) Medicare B Medical Policy January 2000

CPT: 82523

203.00-203.01 Multiple myeloma 242.00-242.91 Thyrotoxicosis 245.2 Chronic lymphocytic thyroiditis (only if thyrotoxic) 246.9 Unspecified disorder of thyroid 252.0 Hyperparathyroidism 256.2 Postablative ovarian failure 256.3 Other ovarian failure 256.8 Other ovarian dysfunction 256.9 Unspecified ovarian dysfunction 268.9 Unspecified vitamin D deficiency 269.3 Mineral deficiency, not elsewhere classified 627.0 Premenopausal menorrhagia 627.1 Postmenopausal bleeding 627.2 Menopausal or female climacteric state 627.4 States associated with artificial menopause 627.8 Other specified menopausal and postmenopausal disorders 627.9 Unspecified menopausal & postmenopausal disorder 731.0 Osteitis deformans without mention of bone tumor (Paget’s disease of bone) 733.00-733.09 Osteoporosis 733.10-733.19 Pathological fracture 733.90 Disorder of bone and cartilage, unspecified 805.8 Fracture of vertebral column without mention of spiral cord injury, unspecified, closed V58.69 Long-term (current) use of other medications

84 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON B

CYTOGENETICS 188.9 Malignant neoplasm of bladder, part unspecified 190.1 Malignant neoplasm of orbit Medicare B Medical Policy February 99 191.0 Malignant neoplasm of cerebrum, except lobes and ventricles 191.1 Malignant neoplasm of frontal lobe CPT: 88230 Tissue culture for non-neoplastic disorders; lymphocyte 191.2 Malignant neoplasm of temporal lobe CPT: 88233 Skin or other solid tissue biopsy 191.3 Malignant neoplasm of parietal lobe CPT: 88235 Amniotic fluid or chronic villus cells 191.4 Malignant neoplasm of occipital lobe CPT: 88237 Bone marrow, blood cells 191.5 Malignant neoplasm of ventricles CPT: 88239 Solid tumor 191.6 Malignant neoplasm of cerebellum Nos CPT: 88240 Cryopreservation, freezing and storage of cells, each cell line 191.7 Malignant neoplasm of brain stem CPT: 88241 Thawing and expansion of frozen cells, each aliquot 191.8 Malignant neoplasm of other parts of brain CPT: 88245 Chromosome analysis for breakage syndromes; baseline Sister 191.9 Malignant neoplasm of brain, unspecified Chromatid Exchange (SCE), 20-25 cells 192.3 Malignant neoplasm of spinal meninges CPT: 88248 Baseline breakage, score 50-100 cells, count 20 cells, 2 197.4 Secondary malignant neoplasm of small intestine, including duodenum karyotypes (e.g. for ataxia telagiectasia, Fanconi anemia, 197.6 Secondary malignant neoplasm of retroperitoneum and peritoneum fragile X) 198.1 Secondary malignant neoplasm of other urinary organs CPT: 88249 Chromosome analysis for breakage syndromes; score 100 cells, 198.2 Secondary malignant neoplasm of skin clastogen stress (e.g., diepoxbutane, mitomycin C, ionizing 198.4 Secondary malignant neoplasm of other parts of nervous system radiation, UV radiation) 198.81 Secondary malignant neoplasm of breast CPT: 88261 Chromosome analysis; count 5 cells, 1 karyotype, with banding 202.80 Lymphomas; unspecified site, extranodal and solid organ sites CPT: 88262 Count 15-20 cells, 2 karyotypes, with banding 202.81 Other lymphomas; lymph nodes of face, head and neck CPT: 88263 Count 45 cells for mosaicism, 2 karyotypes, with banding 202.82 Other lymphomas; intrathoracic lymph nodes CPT: 88264 Analyze 20-25 cells 202.83 Other lymphomas; intra-abdominal lymph nodes CPT: 88267 Chromosome analysis, amniotic fluid or chronic villus, count 15 202.84 Other lymphomas; lymph nodes of axilla and upper limb cells, 1 karyotype, with banding 202.85 Other lymphomas; lymph nodes of inguinal region and lower limb CPT: 88269 Chromosome analysis, in situ for amniotic fluid cells, count cells 202.86 Other lymphomas; intrapelvic lymph nodes from 6-12 colonies, 1 karyotype, with banding 202.87 Other lymphomas; spleen CPT: 88271 Molecular cytogenetics; DNA probe, each (e.g., FISH) 202.88 Other lymphomas; lymph nodes of multiple sites CPT: 88272 Chromosomal in situ hybridization, analyze 3-5 cells (e.g. for 203.00 Multiple myeloma and immunoproliferative neoplasms; without mention of derivatives and markers) remission CPT: 88273 Chromosomal in situ hybridization, analyze 10-30 cells (e.g., for 203.01 Multiple myeloma and immunoproliferative neoplasms; in remission microdeletions) 204.00 Lymphoid leukemia, acute; without mention of remission CPT: 88274 Interface in situ hybridization, analyze 25-99 cells 204.01 Lymphoid leukemia, acute; in remission CPT: 88275 Interphase in situ hybridization, analyze 100-300 cells 204.20 Lymphoid leukemia, subacute; without mention of remission CPT: 88280 Chromosome analysis; additional karyotypes, each study 204.21 Lymphoid leukemia, subacute; in remission CPT: 88283 Additional specialized banding technique (e.g., NOR, C-banding) 204.80 Other lymphoid leukemia; without mention of remission CPT: 88285 Additional cells counted, each study 204.81 Other lymphoid leukemia; in remission CPT: 88289 Additional high resolution study 204.90 Unspecified lymphoid leukemia; without mention of remission CPT: 88291 Cytogenetics and molecular cytogenetics, interpretation and 204.91 Unspecified lymphoid leukemia; in remission report 205.00 Myeloid leukemia, acute; without mention of remission CPT: 88299 Unlisted cytogenetic study 205.01 Myeloid leukemia, acute; in remission 205.10 Myeloid leukemia, chronic; without mention of remission 143.9 Malignant neoplasm of gum, unspecified 205.11 Myeloid leukemia, chronic; in remission 152.1 Malignant neoplasm of jejunum 205.20 Myeloid leukemia, subacute; without mention of remission 152.2 Malignant neoplasm of ileum 205.21 Myeloid leukemia, subacute; in remission 152.3 Malignant neoplasm of Meckel’s diverticulum 205.30 Myeloid sarcoma; without mention of remission 152.8 Malignant neoplasm of other specified sites of small intestine 205.31 Myeloid sarcoma; in remission 158.0 Malignant neoplasm of retroperitoneum 205.80 Other myeloid leukemia; without mention of remission 171.0 Malignant neoplasm of head, face and neck 205.81 Other myeloid leukemia; in remission 171.2 Malignant neoplasm of upper limb, including shoulder 205.90 Unspecified Myeloid leukemia, without mention of remission 171.3 Malignant neoplasm of lower limb, including hip 205.91 Unspecified Myeloid leukemia, in remission 171.4 Malignant neoplasm of thorax 208.00 Leukemia of unspecified cell type; without mention of remission 171.5 Malignant neoplasm of abdomen 208.01 Leukemia of unspecified cell type; in remission 171.6 Malignant neoplasm of pelvis 208.20 Leukemia of unspecified cell type, subacute; without mention of remission 171.7 Malignant neoplasm of trunk, unspecified 208.21 Leukemia of unspecified cell type, subacute; in remission 171.8 Malignant neoplasm of other specified sites of connective and other soft tissue 208.80 Other leukemia of unspecified cell type; without mention of remission 171.9 Malignant neoplasm of connective and other soft tissue, site unspecified 208.81 Other leukemia of unspecified cell type; in remission 173.9 Other malignant neoplasm of skin, site unspecified 208.90 Unspecified leukemia; without mention of remission 188.0 Malignant neoplasm of trigone of urinary bladder 208.91 Unspecified leukemia; in remission 188.1 Malignant neoplasm of dome of urinary bladder 223.3 Benign neoplasm of bladder 188.2 Malignant neoplasm of lateral wall of urinary bladder 230.0 Carcinoma in situ of lip, oral cavity, and pharynx 188.3 Malignant neoplasm of anterior wall of urinary bladder 231.0 Carcinoma in situ of larynx 188.4 Malignant neoplasm of posterior wall of urinary bladder 232.9 Carcinoma in situ of skin, site unspecified 188.5 Malignant neoplasm of bladder neck 233.0 Carcinoma in situ of breast 188.6 Malignant neoplasm of ureteric orifice 233.7 Carcinoma in situ of bladder 188.7 Malignant neoplasm of urachus 233.9 Carcinoma in situ of other and unspecified urinary organs 188.8 Malignant neoplasm of other specified sites of bladder 234.0 Carcinoma in situ of eye

SEPTEMBER 2000 85 LMRPs WASHINGTON B (509) 927-6250 • 1-800-433-1583

236.7 Neoplasm of uncertain behavior of bladder 078.5 Cytomegaloviral disease 238.7 Other lymphatic and hematopoietic tissues (includes myelodysplastic syndrome) 084.9 Other pernicious complications of malaria 239.2 Neoplasm of unspecified nature of bone, soft tissue and skin 130.5 Hepatitis due to toxoplasmosis 239.3 Neoplasm of unspecified nature of breast 153.0-154.1 Malignant neoplasm of hepatic flexure 256.3 Ovarian dysfunction; other ovarian failure: premature menopause; primary ovarian 154.8-155.0 Malignant neoplasm of other sites of rectum, rectosigmoid junction, and anus failure 155.2 Malignant neoplasm of liver, not specified as primary or secondary 257.2 Testicular dysfunction; other testicular hypofuntion defective biosynthesis of 157.0-157.9 Malignant neoplasm of head of pancreas testicular androgen 174.0-175.9 Malignant neoplasm of nipple and areola of female breast 259.0 Delay in sexual development and puberty, not elsewhere classified 186.9 Malignant neoplasm of other and unspecified testis 742.59 Other specified anomalies of spinal cord, other (includes myelodysplasia) 197.5 Secondary malignant neoplasm of large intestine and rectum 752.8 Congenital anomalies of genital organs; other specified anomalies of genital 197.7-197.8 Malignant neoplasm of liver, specified as secondary organs 198.81 Secondary malignant neoplasm of breast 758.0 Chromosomal anomalies; Down’s syndrome 211.5-211.6 Benign neoplasm of liver and biliary passages 758.1 Patau’s syndrome 230.3 Carcinoma in situ of colon 758.2 Edward’s syndrome 230.8-230.9 Carcinoma in situ of liver and biliary system 758.3 Autosomal deletion syndromes (antimongolism syndrome and cri-du-chat 235.0-235.3 Neoplasm of uncertain behavior of major salivary glands syndrome) 235.5 Neoplasm of uncertain behavior of other and unspecified digestive organs 758.4 Balance autosomal translocation in normal individual 238.3 Neoplasm of uncertain behavior of breast 758.5 Other conditions due to autosomal anomalies (accessory autosomes, NEC) 239.0 Neoplasm of unspecified nature of digestive system 758.6 Gonadal dysgenesis (ovarian dysgenesis, Turner’s syndrome, XO syndrome) 275.0-275.1 Disorders of iron metabolism 758.7 Klinefelter’s syndrome 277.00 Cystic fibrosis 758.81 Other conditions due to sex chromosome anomalies 291.0-291.5 Alcohol withdrawal delirium 758.89 Other conditions due to chromosome anomalies 303.00-303.93 Acute alcoholic intoxication in alcoholism, unspecified drinking behavior 758.9 Conditions due to anomaly of unspecified chromosome 305.00-305.92 Alcohol abuse, unspecified drinking behavior 570-574.51 Acute and subacute necrosis of liver FLOW CYTOMETRY 575.0-577.9 Acute cholecystitis 774.4 Perinatal jaundice due to hepatocellular damage Medicare B Medical Policy April 10, 1997 789.1 Hepatomegaly CPT: 88180 790.4-790.5 Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase (LDH) 042 Human immunodeficiency virus (HIV) disease V11.3 Personal history of alcoholism 200.00-200.88 Lymphosarcoma and reticulosarcoma V42.7 Liver replaced by transplant 201.00-201.98 Hodgkin’s disease V58.69 Long Term (current) use of other medication 202.00-202.98 Other malignant neoplasm’s of lymphoid and histiocytic tissue 203.00-203.81 Multiple myeloma and immunoproliferative neoplasm’s GLYCATED HEMOGLOBIN AND GLYCATED 204.00-204.91 Lymphoid leukemia 205.00-205.91 Myeloid leukemia PROTEIN 206.00-206.91 Monocytic leukemia Medicare B Medical Policy November 1996 207.00-207.81 Other specified leukemia 208.00-208.91 Leukemia of unspecified cell type CPT: 82985 Glycated protein 238.7 Myelodysplastic syndrome CPT: 83036 Hemoglobin; glycated 785.6 Enlargement of lymph node (lymphadenopathy) 996.80-996.89 Complications of transplanted organ V10.60-V10.69 Leukemia 250.00-250.93 Diabetes mellitus V42.0-V42.8 Organ or tissue replaced by transplant 648.00-648.04 Other current conditions in the mother, classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium; Diabetes CPT: 88182 648.80-648.84 Other current conditions in the mother, classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium; abnormal glucose tolerance 174.0-174.9 Malignant neoplasm of female breast 790.2 Abnormal glucose tolerance 175.0-175.9 Malignant neoplasm of male breast 183.0 Malignant neoplasm of ovary 183.8 Other specified sites of uterine adnexa HIV-1 VIRAL LOAD TESTING 185 Malignant neoplasm of prostate Medicare B Medical Policy May 1999 188.0-188.9 Malignant neoplasm of bladder 153.0-153.8 Malignant neoplasm of colon CPT: G0100 CPT: 87534 HIV-1, direct probe technique GAMMA GLUTAMYLTRANSFERASE (GGT) CPT: 87535 HIV-1, amplified probe technique CPT: 87536 quantification, HIV, RNA, QUANT, HIVB.UNA Medicare B Medical Policy May 1, 1998 CPT: 87537 HIV-2, direct probe technique CPT: 87538 HIV-2, amplified probe technique CPT: 82977 CPT: 87539 HIV-2, quantification

017.90-017.96 Tuberculosis of other specified organs, unspecified examination V01.7 Exposure to HIV Virus 070.0-070.9 Viral hepatitis a with hepatic coma V08 Asymptomatic Human Immunodeficiency Virus (HIV) infection status 072.71 Mumps hepatitis 042 Acquired Immune Deficiency Syndrome (AIDS) 074.8 Other specified diseases due to coxsackie virus 079.53 Human immunodeficiency virus, Type 2 [HIV-2] 075 Infectious mononucleosis 795.71 Non-specific serologic evidence of human immunodeficiency virus (HIV)

86 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON B

LIPID PROFILE AND CHOLESTEROL 557.1 Chronic vascular insufficiency of intestine 570 Acute and subacute necrosis of liver TESTING 571.0-571.8 Chronic liver disease and cirrhosis 572.0-572.8 Liver abscess and sequelae of chronic liver disease Medicare B Medical Policy February 1997 573.0-573.8 Other disorders of liver 574.00-574.91 Cholelithiasis CPT: 80061 Lipid panel (this panel must include 82465, 83718, and 84478) 575.2 Obstruction of gallbladder CPT: 82465 Cholesterol, serum, total 575.6 Cholesterolosis of gallbladder CPT: 83715 Lipoprotein, blood; electophorectic separation and quantitation 576.2 Obstruction of bile duct CPT: 83717 ultracentrifugation and quantitiation 576.8 Other specified disorders of biliary tract CPT: 83718 Lipoprotein, direct measurement; high density cholesterol (HDL 577.0-577.8 Diseases of pancreas cholesterol) 579.3 Other and unspecified postsurgical nonabsorption CPT: 83719 Direct measurement, VLDL cholesterol 579.8 Other specified intestinal malabsorption CPT: 83721 Direct measurement, LDL cholesterol 581.0-581.9 Nephrotic syndrome CPT: 84478 Triglycerides 584.5 Acute renal failure with lesion of tubular necrosis 588.1 Nephrogenic diabetes insipidus 240.0 Goiter, specified as simple 588.8 Other specified disorders resulting from impaired renal function 241.0-241.9 Nontoxic nodular goiter 646.70-646.73 Liver disorders in pregnancy (specify 5th digit 0,1, or 3) 242.00-242.91 Thyrotoxicosis with or without goiter 648.10-648.14 Thyroid dysfunction 243-244.8 Hypothyroidism 696.0-696.1 Psoriatic arthropathy; and other psoriasis (following treatment with high-risk 245.0-245.8 Thyroiditis medication, e.g., esterinate, NEC. List the drug used and the condition treated 246.0-246.8 Other disorders of the thyroid 746.85 Coronary artery anomaly 250.00-250.93 Diabetes mellitus 751.61 Biliary atresia 255.0 Cushing’s syndrome 764.10-764.19 “Light-for-dates” with signs of fetal malnutrition 260 Kwashiorkor 786.50 Chest pain, unspecified 261 Nutritional marasmus 790.6 Abnormal blood chemistry - Hyperuricemia 262 Other severe protein-calorie malnutrition V58.69 Long-term (current) use of other (high risk) medications 263.0-263.1 Malnutrition 263.8-263.9 Other and unspecified protein-calorie malnutrition 270.0 Disturbances of amino-acid transport MAGNESIUM 271.1 Galactosemia Medicare B Medical Policy September 1, 1998 272.0-272.8 Disorders of lipoid metabolism 274.0 Gouty arthropathy CPT: 83735 274.10-274.19 Gouty nephropathy 303.90-303.92 Other and unspecified alcohol dependence 250.10-250.13 Diabetes with ketoacidosis 362.13 Changes is vascular appearance, vascular sheathing of retina 250.20-250.23 Diabetes with hyperosmolarity 362.82 Retinal exudates and deposits 250.30-250.33 Diabetes with other coma 379.22 Crystalline deposits in vitreous 250.40-250.43 Diabetes with renal manifestations 388.00 Degenerative and vascular disorders of the ear, unspecified 250.50-250.53 Diabetes with ophthalmic manifestations 401.1-401.1 Essential hypertension 250.60-250.63 Diabetes with neurological manifestations 402.00-402.11 Hypertensive heart disease 250.70-250.73 Diabetes with peripheral circulatory disorders 403.00-403.11 Hypertensive renal disease 250.80-250.83 Diabetes with other specified manifestations 404.00-404.13 Hypertensive heart and renal disease 250.90-250.93 Diabetes with unspecified complication 405.01-405.19 Secondary hypertension 252.0 Hyperparathyroidism 410.00-410.82 Acute myocardial infarction 252.1 Hypoparathyroidism 411.0-411.89 Other acute and subacute forms of ischemic heart disease 252.8 Other specified disorders of the parathyroid gland 412 Old myocardial infarction 252.9 Unspecified disorders of parathyroid gland 413.0-413.9 Angina pectoris 255.1 Hyperaldosteronism 414.00-414.8 Other forms of chronic ischemic heart disease 259.3 Ectopic hormone secretion, not elsewhere classified 427.0-427.89 Cardiac dysrhythmias 260 Kwashiorkor 428.0-428.1 Heart failure 261 Nutritional marasmus 429.2 Cardiovascular disease, unspecified 262 Other severe, protein-calorie malnutrition 431-432 Subarachnoid hemorrhage; Intracerebral hemorrhage 263.0 Malnutrition of moderate degree 432.0-432.1 Other intracranial hemorrhage 263.8 Other protein-calorie malnutrition 433.00-433.81 Occlusion and stenosis of precerebral arteries 263.9 Unspecified protein-calorie malnutrition 434.00-434.11 Occlusion of cerebral arteries 275.2 Disorders of magnesium metabolism 435.0-435.8 Transient cerebral ischemia 275.40-275.49 Disorders of calcium metabolism 436 Acute, but ill-defined cerebrovascular disease 276.2 Acidosis 437.0-437.8 Other and ill-defined cerebrovascular disease 276.4 Mixed acid-base balance disorder 438.0-438.9 Late effects of cerebrovascular disease 276.5 Volume depletion 440.0-440.9 Atherosclerosis 276.7 Hyperpotassemia 441.0-441.9 Aortic aneurysm and dissection 276.8 Hypopotassemia 443.0-443.89 Other peripheral vascular disease 276.9 Electrolyte and fluid disorders not elsewhere classified 444.0-444.89 Arterial embolism and thrombosis 278.8 Other hyperalimentation 446.0-446.7 Polyarteritis nodosa and allied conditions 286.9 Other and unspecified coagulation defects 447.0-447.8 Other disorders of arteries and arterioles 289.59 Diseases of the spleen, other 448.0-448.9 Disease of capillaries 293.0-293.1 Transient acute and subacute delirium

SEPTEMBER 2000 87 LMRPs WASHINGTON B (509) 927-6250 • 1-800-433-1583

298.9 Unspecified psychosis 635.80-635.82 with unspecified complications 303.90-303.93 Other and unspecified alcohol dependence, chronic alcoholism 636.10-636.12 illegally induced abortion; complicated by delay or excessive hemorrhage 307.1 Anorexia nervosa 636.30-636.32 complicated by renal failure 307.20 Tic disorder, unspecified 636.40-636.42 complicated by metabolic disorder 307.22 Chronic motor tic disorder 636.50-636.52 complicated by shock 307.50 Eating disorder, unspecified 636.60-636.62 complicated by embolism 307.51 Bulimia 636.70-636.72 with other specified complications 307.52 Pica 636.80-636.82 with unspecified complications 307.59 Other disorders of eating 637.10-637.12 Unspecified abortion; complicated by delay or excessive hemorrhage 333.2 Myoclonus 637.30-637.32 complicated by renal failure 333.3 Tics of organic origin 637.40-637.42 complicated by metabolic disorder 336.1 Vascular myelopathies 637.50-637.52 complicated by shock 345.60-345.61 Infantile spasms 637.60-637.62 complicated by embolism 359.5 Myopathy in endocrine diseases classified elsewhere 637.70-637.72 with other specified complications 359.8 Other myopathies 637.80-637.82 with unspecified complications 359.9 Myopathy, unspecified 638.1-638.9 Failed attempted abortion; complicated by delay or excessive hemorrhage 410.00-410.02 Acute myocardial infarction of anterolateral wall 639.1 Complications following abortion and ectopic and molar pregnancies; delayed or 410.10-410.12 Acute myocardial infarction of other anterior wall excessive hemorrhage 410.20-410.22 Acute myocardial infarction of inferolateral wall 639.3 renal failure 410.30-410.32 Acute myocardial infarction of inferoposterior wall 639.4 metabolic disorders 410.40-410.43 Acute myocardial infarction of other inferior wall 639.5 shock 410.50-410.52 Acute myocardial infarction of other lateral wall 639.6 embolism 410.60-410.62 Acute myocardial infarction, true posterior wall 639.8 Other and unspecified complications following abortion or ectopic and molar 410.70-410.72 Acute myocardial infarction, subendocardial pregnancy 410.80-410.82 Acute myocardial infarction of other specified site 639.9 Unspecified complication following abortion or ectopic and molar pregnancy 410.90-410.92 Acute myocardial infarction of unspecified site 640.00,640.01, 411.81 Coronary occlusion without myocardial infarction 640.03 Threatened abortion 415.11 Latrogenic pulmonary embolism and infarction 640.80,640.81, 415.19 Other pulmonary embolism and infarction 640.83 Other specified hemorrhage in early pregnancy 427.0-427.2 Paroxysmal supraventricular, ventricular, and unspecified tachycardia 640.90,640.91, 427.31-427.32 Atrial fibrillation and flutter 640.93 Unspecified hemorrhage in early pregnancy 427.41-427.42 Ventricular fibrillation and flutter 641.00,641.01, 427.5 Cardiac arrest 641.03 Placenta previa without hemorrhage 427.60-427.61 Premature beats 641.10,641.11, 427.69 Premature beats, other 641.13 Hemorrhage from placenta previa 427.81 Sinoatrial node dysfunction 641.20,641.21, 427.89 Sinoatrial node dysfunction, other 641.23 Premature separation of placenta 427.9 Cardiac dysrhythmia 641.30,641.31, 429.79 Certain sequelae of myocardial infarction not elsewhere classified, other 641.33 Antepartum hemorrhage associated with coagulation defects 429.89 Other ill-defined heart disease 641.80,641.81, 458.0-458.2 Hypotension 641.83 Other antepartum hemorrhage 458.9 Hypotension, unspecified 641.90- 536.2 Persistent vomiting 641.92 Unspecified antepartum hemorrhage 579.0 Celiiac disease 642.00-642.04 Hypertension complicating pregnancy, childbirth and the pueperium 579.2 Blind loop syndrome 642.10-642.14 Hypertension secondary to renal disease, complicating pregnancy, childbirth, and 579.3 Other and unspecified postsurgical nonabsorption the puerperium 579.8 Other specified intestinal malabsorption 642.20-642.24 Other pre-existing hypertension complicating pregnancy, childbirth and the 579.9 Unspecified intestinal malabsorption puerperium 584.5-584.9 Acute renal failure 642.30-642.34 Transient hypertension of pregnancy 585 Chronic renal failure 642.40-642.44 Mild or unspecified pre-eclampsia 586 Renal failure, unspecified 642.50-642.54 Severe pre-eclampsia 588.8 Other specified disorder resulting from impaired renal function 642.60-642.64 Eclampsia 593.81 Vascular disorders of kidney 642.70-642.74 Pre-eclampsia or eclampsia superimposed on pre-existing hypertension 632 Missed abortion 642.90-642.94 Unspecified hypertension complicating pregnancy, childbirth or the puerperium 634.10-634.12 Spontaneous abortion; complicated by delay or excessive hemorrhage 643.10,643.11, 634.30-634.32 complicated by renal failure 643.13 Hyperemesis gravidarum with metabolic disturbance 634.40-634.42 complicated by metabolic disorder 643.20,643.21, 634.50-635.52 complicated by shock 643.23 Late vomiting of pregnancy 634.60-635.62 complicated by embolism 643.80,643.81, 634.70-634.72 with other specified complications 643.83 Other vomiting complicating pregnancy 634.80-634.82 with unspecified complications 643.90,643.91, 635.10-635.12 Legally induced abortion; complicated by delay or excessive hemorrhage 643.93 Unspecified vomiting of pregnancy 635.30-635.32 complicated by renal failure 646.20-646.24 Unspecified renal disease in pregnancy without mention of hypertension 635.40-635.42 complicated by metabolic disorder 646.80-646.84 Other specified complications of pregnancy 635.50-635.52 complicated by shock 646.90-646.91 Unspecified complication of pregnancy 635.60-635.62 complicated by embolism 646.93 Antepartum condition or complication 635.70-635.72 with other specified complications 648.00-648.04 Diabetes mellitus, pregnancy

88 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON B

648.90-648.94 Other current conditions of pregnancy, classified elsewhere 796.2 Elevated blood pressure reading without diagnosis of hypertension 655.80,655.81, 799.4 Cachexia 655.83 Other known or suspected fetal abnormality 958.4 Traumatic shock 655.90,655.91, 995.2 Unspecified adverse effect of drug, medicinal and biological substance, 655.93 Unspecified fetal abnormality amphotericin B 656.00,656.01, 997.1 Cardiac complications 656.03 Fetal-maternal hemorrhage 998.0 Postoperative shock 656.30,656.31, 998.9 Unspecified complication of procedure, not elsewhere classified 656.33 Fetal distress 999.9 Other and unspecified complications of medical care, not elsewhere classified, 656.40,656.41, dialysis 656.43 Intrauterine death V56.0 Extracorporeal dialysis 666.00 Postpartum hemorrhage, third-stage, unspecified as to episode of care or not V56.8 Other dialysis applicable V58.1 Chemotherapy, (cis-platinum) 666.02 Postpartum hemorrhage, third-stage,delivered with mention of postpartum V58.69 Long term (current) use of other medications (high risk) complication 666.04 Postpartum hemorrhage, third-stage,postpartum condition or complication PARTIAL THROMBOPLASTIN TIME 666.10 Other immediate postpartum hemorrhage, unspecified as to episode of care or not applicable Medicare B Medical Policy May 1, 1998 666.12 Other immediate postpartum hemorrhage, delivered with mention of postpartum complication CPT: 85730 666.14 Other immediate postpartum hemorrhage, postpartum condition or complication 666.20 Delayed and secondary postpartum hemorrhage 286.0 Congenital factor VIII disorder - Hemophilia A 666.22 Delayed and secondary postpartum hemorrhage delivered with mention of 286.1 Congenital factor IX disorder - Hemophilia B postpartum complication 286.2-286.3 Other congenital factor deficiencies 666.24 Delayed and secondary postpartum hemorrhage postpartum condition or 286.4 Von Willebrand’s disease complication 286.5 Hemorrhagic disorder due to circulating anticoagulants 668.10-668.14 Cardiac complications 286.6 Defibrination syndrome 668.80-668.84 Other complications of anesthesia or other sedation in labor and delivery 286.7 Acquired coagulation factor deficiency 668.90-668.94 Unspecified complication of anesthesia or other sedation in labor and delivery 286.9 Other and unspecified coagulation defects 669.10-669.14 Shock during or following labor and delivery 287.9 Unspecified hemorrhagic conditions 669.20-669.24 Maternal hypotension syndrome 570 Acute and subacute necrosis of liver 669.30-669.32 Acute renal failure following labor and delivery 710.0 Systemic lupus erythematosus 669.34 postpartum condition or complication 710.1 Systemic sclerosis 669.40-669.44 Other complications of obstetrical surgery and procedures 710.2 Sicca syndrome 669.80-669.84 Other complications of delivery 710.3 Dermatomyositis 669.90-669.94 Unspecified complication of labor and delivery 782.7 Spontaneous ecchymoses 673.20-673.24 Obstetrical blood-clot embolism 924.9 Contusion, unspecified site 728.9 Unspecified disorders of muscle, ligament, and fascia 964.2 Poisoning by agents primarily affecting blood constituents, anticoagulants 729.82 Other musculoskeletal symptoms referable to limbs, cramp V58.61 Long-term (current) use of anticoagulants 760.0 Maternal hypertensive disorders 760.1 Maternal renal and urinary tract diseases PROSTATE SPECIFIC ANTIGEN (PSA) 760.4 Maternal nutrition disorders 760.71 Influences affecting fetus; alcohol Medicare B Medical Policy September 1996 760.8 Other specified maternal conditions affecting fetus or newborn 763.81-763.83 Other specified complications of labor and delivery affecting fetus or CPT: 84153 newborn,abnormality in fetal heart rate or rhythm 763.89 Unspecified complication of labor and delivery affecting fetus or newborn 170.2 Malignant neoplasm of vertebral column, excluding sacrum and coccyx 763.9 Unspecified complication of labor and delivery affecting fetus or newborn 185 Malignant neoplasm of prostate 780.01-780.02 Coma 188.5 Malignant neoplasm of bladder neck 780.09 Other alterations of consciousness 188.8 Malignant neoplasm of other specified sites of bladder 780.2 Syncope and collapse 196.5 Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region 780.31 Febrile convulsions and lower limb 780.39 Convulsions 196.6 Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes 780.71 Chronic fatigue syndrome 196.8 Secondary and unspecified malignant neoplasm of lymph nodes of multiple sites 780.79 Malaise and fatigue 198.5 Secondary malignant neoplasm of bone and bone marrow 781.0 Abnormal involuntary movements 198.82 Secondary malignant neoplasm, genital organs 781.7 Tetany 222.2 Benign neoplasm of prostate 783.0 Anorexia 233.4 Carcinoma in situ of prostate 783.2 Abnormal loss of weight 236.5 Neoplasm of uncertain behavior, prostate 783.3 Feeding difficulties and mismanagement 239.5 Neoplasm of unspecified nature, other genitourinary organs 783.9 Other symptoms concerning nutrition, metabolism, and development 600 Hyperplasia of the prostate 785.0 Tachycardia, unspecified 790.93 Elevated prostate specific antigen (PSA) 785.50-785.51 Cardiogenic shock; shock unspecified V10.46 Personal history of malignant neoplasm, prostate 785.59 Shock, other V71.1 Observation for suspected malignant neoplasm 790.6 Other abnormal blood chemistry 794.31 Abnormal electrocardiogram 794.4 Abnormal kidney test

SEPTEMBER 2000 89 LMRPs WASHINGTON B (509) 927-6250 • 1-800-433-1583

PROSTATIC ACID PHOSPHATASE (PAP) 719.15 Hemarthrosis involving pelvic region and thigh 719.16 Hemarthrosis involving lower leg Medicare B Medical Policy May 1, 1998 719.19 Hemarthrosis involving multiple sites 746.00-746.9 Congenital pulmonary valve anomaly, unspecified CPT: 84066 782.7 Spontaneous ecchymoses 784.7-784.8 Epistaxis 185 Malignant neoplasm of prostate 786.3 Hemoptysis 198.5 Secondary malignant neoplasm of bone and bone marrow 789.1 Hepatomegaly 222.2 BenigN neoplasm of prostate 789.5 Ascites 233.4 Carcinoma in situ of prostate 790.92 Abnormal coagulation profile 236.5 Neoplasm of uncertain behavior of prostate 852.00-852.59 Subarachnoid hemorrhage following injury, without mention of open intracranial 239.5 Neoplasm of unspecified nature of other genitourinary organs wound, with state of consciousness unspecified 790.93 Elevated prostate specific antigen (PSA) 964.2 Poisoning by anticoagulants V10.46 Personal history of malignant neoplasm of prostate 995.2 Unspecified adverse effect of drug, medicinal and biological substance, NEC V12.3 Personal history of diseases of blood and blood-forming organs PROTHROMBIN TIME V15.1 Personal history of surgery to heart and great vessels, presenting hazards to health Medicare B Medical Policy September 1996 V42.2 Heart valve replaced by transplant V42.7 Liver replaced by transplant CPT: 85610 V43.2 Heart replaced by other means V43.3 Heart valve replaced by other means 070.0-070.9 Viral hepatitis a with hepatic coma V43.4 Blood vessel replaced by other means 269.0 Deficiency of vitamin K V43.60 Unspecified joint replacement status 285.1 Acute posthemorrhagic anemia V58.61 Long term (current) use of anticoagulants 286.0-287.9 Congenital factor eight disorder 290.40-290.43 Arteriosclerotic dementia, uncomplicated RETICULOCYTE COUNT POLICY (RTC) 325 Phlebitis and thrombophlebitis of intracranial venous sinuses 362.30-367.37 Retinal vascular occlusion, unspecified Medicare B Medical Policy December 1996 386.2 Vertigo of central origin 386.50 Labyrinthine dysfunction, unspecified CPT: 85044 Blood count; reticulocyte count, manual 394.0-395.0 Mitral stenosis CPT: 85045 Blood count; reticulocyte count, flow cytometry 395.2 Rheumatic aortic stenosis with insufficiency 396.0-396.9 Mitral valve stenosis and aortic valve stenosis 280.0-285.9 Anemias 410.00-410.92 Acute myocardial infarction of anterolateral wall, episode of care unspecified 411.1 Intermediate coronary syndrome 411.81-411.89 Other acute and subacute forms of ischemic heart disease, acute ischemic heart disease without myocardial infarction 413.0-414.05 Angina decubitus 414.8-415.19 Other specified forms of chronic ischemic heart disease 416.9 Chronic pulmonary heart disease, unspecified 424.0-424.99 Mitral valve disorders 425.0-425.9 Endomyocardial fibrosis 427.0-429.4 Paroxysmal supraventricular tachycardia 429.79 Certain sequelae of myocardial infarction, NEC, Other 432.0-437.1 Nontraumatic extradural hemorrhage 437.6 Nonpyogenic thrombosis of intracranial venous sinus 440.0-440.9 Atherosclerosis of aorta 443.0-444.9 Raynaud’s syndrome 447.1 Stricture of artery 451.0-453.9 Phlebitis and thrombophlebitis of superficial vessels of lower extremities 459.0-459.81 Hemorrhage, unspecified 514 Pulmonary congestion and hypostasis 569.3 Hemorrhage of rectum and anus 571.0-571.9 Alcoholic fatty liver 572.2 Hepatic coma 572.4 Hepatorenal syndrome 572.8 Other sequelae of chronic liver disease 573.9 Unspecified disorder of liver 577.0 Acute pancreatitis 578.0-578.9 Hematemesis 579.2 Blind loop syndrome 599.7 Hematuria 671.20-671.54 Superficial thrombophlebitis complicating pregnancy and the puerperium, unspecified as to episode of care 671.90-671.94 Unspecified venous complication of pregnancy and the puerperium, unspecified as to episode of care 673.00-673.84 Obstetrical air embolism, unspecified as to episode of care

90 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON B

RHEUMATOID (RA) FACTOR TEST 120.0-120.9 Schistosmiasis 124 Trichinosis Medicare B Medical Policy May 1998 135 Sarcoidosis 201.90-201.98 Hodgkin’s disease, unspecified CPT: 86430 Rheumatoid factor test; qualitative 245.1 Subacute thyroiditis CPT: 86431 Quantitative 245.2 Chronic lymphocytic thyroiditis 270.0 Cystinosis 015.00-015.26 Tuberculosis of vertebral column, unspecified examination 274.0 Gouty arthropathy 015.80-015.96 Tuberculosis of other specified joint, unspecified examination 279.4 Autoimmune disease, NEC 030.9 Leprosy, unspecified 287.0 Allergic purpura 075 Infectious mononucleosis 324.0 Intracranial abscess 095.8 Other specified forms of late symptomatic syphilis 357.0 Guillain-Barre syndrome 135 Sarcoidosis 362.31 Central retinal artery occlusion 273.2 Other paraproteinemias 368.11 Sudden visual loss 274.0 Gouty arthropathy 368.2 Diplopia 284.8 Other specified aplastic anemia’s 377.30-377.39 Optic neuritis 288.0 Agranulocytosis 390 Rheumatic fever without mention of heart involvement 289.4 Hypersplenism 391.0 Acute rheumatic pericarditis 421.9 Acute endocarditis, unspecified 391.1 Acute rheumatic endocarditis 443.0 Raynaud’s syndrome 391.2 Acute rheumatic myocarditis 446.0-446.7 Polyarteritis nodosa 391.8 Other acute rheumatic heart disease 447.1-447.9 Stricture of artery 420.0 Acute pericarditis/disease classified elsewhere 516.3 Idiopathic fibrosing alveolitis 420.90-420.99 Other and unspecified pericarditis 696.0 Psoriatic arthropathy 421.0 Acute and subacute bacterial endocarditis 701.0 Circumscribed scleroderma 421.1 Acute and subacute infective endocarditis/disease classified elsewhere 710.0-710.9 Systemic lupus erythematosus 421.9 Acute endocarditis, unspecified 711.10-711.99 Arthropathy, site unspecified, associated with reiter’s disease and nonspecific 422.0 Acute myocarditis/disease classified elsewhere urethritis 422.90-422.99 Other and unspecified acute myocarditis 712.10-712.99 Chondrocalcinosis, due to dicalcium phosphate crystals, involving unspecified site 425.4 Cardiomyopathies 713.0-713.8 Arthropathy associated with other endocrine and metabolic disorders 429.4 Postcardiotomy 714.0-714.89 Rheumatoid arthritis 430-437.9 Cerebrovascular disease 714.9 Unspecified inflammatory polyarthropathy 446.0 Polyarteritis nodosa 715.00-715.98 Osteoarthrosis, generalized, involving unspecified site 446.1-446.4 Polyarteritis nodosa, up to and including giant cell arteritis 716.00-716.99 Kaschin-Beck disease, site unspecified 446.5 Giant cell arteritis 719.00-719.99 Effusion of joint, site unspecified 447.6 Arteritis, unspecified 725 Polymyalgia rheumatica 483.0 Mycoplasma pneumonia 729.0-729.2 Rheumatism, unspecified and fibrositis 487.1 Influenza 729.81-729.89 Swelling of limb 491.0-491.9 Chronic bronchitis 789.2 Splenomegaly 513.0-513.1 Abscess of lung 515 Post inflammatory pulmonary fibrosis SEDIMENTATION RATE, ERYTHROCYTE, 540.9 Acute appendicitis 555.0-555.9 Regional enteritis AUTOMATED AND NON-AUTOMATED 556.9 Ulcerative colitis (SED RATE) 562.01 Diverticulitis of small intestine 562.03 Diverticulitis of small intestine with hemorrhage Medicare B Local Medical Review Policy December 15, 1998 562.11 Diverticulitis of colon (without mention of hemorrhage) 562.13 Diverticulitis of colon with hemorrhage CPT: 85651 570 Acute and Subacute Necrosis of Liver CPT: 85652 575.12 Acute and chronic cholecystitis 577.0 Acute Pancreatitis 006.3 Amebic liver abscess 580.9 Acute glomerulonephritis, NOS, hemorrhagic 011.00-011.96 Pulmonary tuberculosis 585 Chronic renal failure 013.00-013.06 Tuberculosis meningitis 614.9 Pelvic inflammatory disease 018.90-018.96 Disseminated tuberculosis 682.9 Other cellulitis and abscess, unspecified 021.9 Tularemia 694.4 Pemphigus 023.9 Brucellosis 695.2 Erythema nodosum 030.9 Leprosy 695.4 Lupus Erythematosus (discoid) 038.0 Streptococcal septicemia 696.0 Psoriatic arthropathy 039.9 Actinomycosis 710.0 Systemic lupus erythematosus 041.00-041.09 Streptococcus, up to and including other streptococcus 710.1 Systemic sclerosis 070.9 Viral hepatitis 710.2 Sicca syndrome 073.9 Psittacosis 710.3 Dermatomyositis 085.9 Leishmaniasis 710.4 Polymyositis 087.9 Relapsing fever 710.5 Eosinophilia myalgia syndrome 100.9 Leptospirosis 710.8 Other specified diffuse diseases of connective tissue 114.9 Coccidioidomycosis 710.9 Unspecified diffuse connective tissue disease 116.0 Blastomycosis 711.00-711.09 Pyogenci arthritis

SEPTEMBER 2000 91 LMRPs WASHINGTON B (509) 927-6250 • 1-800-433-1583

711.10-711.19 Arthropathy associated with Reiter’s disease and non-specific urethritis IRON/IBC/TRANSFERRIN/FERRITAN- 711.20-711.29 Arthropathy in Behcet’s syndrome 711.30-711.39 Postdysenteric arthropathy SERUM IRON STUDIES 711.40-711.49 Arthropathy associated with other bacterial diseases Medicare B Medical Policy September 1996 711.50-711.59 Arthropathy associated with other viral diseases 711.60-711.69 Arthropathy associated with mycoses CPT: 82728 Ferritin 711.70-711.79 Arthropathy associated with helminthiasis CPT: 83540 Iron 711.80-711.89 Arthropathy associated with other infectious and parasitic diseases CPT: 83550 Iron binding capacity 711.90-711.99 Unspecified crystal arthropathy CPT: 84466 Transferrin 714.0 Rheumatoid arthritis 714.1 Felty’s syndrome 238.4 Polycythemia vera 714.2 Other rheumatoid arthritis with visceral or systemic involvement 250.00-250.93 Insulin dependant diabetes mellitus 714.30-714.33 Juvenile chronic polyarthritis 275.0 Disorders of iron metabolism (hemachromatosis) 714.4 Chronic postrheumatic arthropathy 280.0-280.9 Iron deficiency anemias 714.81-714.89 Other specified inflammatory polyarthropathies 281.0-281.2 Pernicious anemia; Other vitamin B12 deficiency; Folate-deficiency anemia 714.9 Unspecified inflammatory polyarthropathy 282.3 Other hemolytic anemias due to enzyme deficiency 715.00-715.98 Osteoarthrosis and allied disorders 282.4 Thalassemia 716.00-716.09 Kashin-Beck disease 282.60 Sickle-cell anemia 716.20-716.29 Allergic arthritis 282.63 Sickle-cell/Hb-C disease 716.50-716.59 Unspecified polyarthropathy or polyarthritis 282.69 Sickle-cell anemia, other 716.60-716.68 Unspecified monoarthritis 282.7 Other hemoglobinopathies 716.80-716.89 Other specified arthropathy 282.9 Hereditary hemolytic anemia, unspecified 716.90-716.99 Arthropathy, unspecified 283.9 Acquired-hemolytic anemia, unspecified 719.00-719.09 Effusion of joint 284.8 Other specified aplastic anemias 719.10-719.19 Hemarthrosis 285.0-285.1 Siberoblastic anemia; Acute post hemorrhagic anemia 719.20-719.29 Villondular synovitis 285.9 Anemia, unspecified 719.30-719.39 Palindromic rheumatism 307.52 Pica 719.40-719.49 Arthralgia 425.4 Other primary cardiomyopathies 720.0 Ankylosing spondylitis 536.0 Achlorhydria 720.1 Spinal enthesopathy 571.5 Cirrhosis of liver without mention of alcohol 720.2 Sacroillitis, not elsewhere classified 571.8 Other chronic nonalcoholic liver disease 720.81-720.89 Other inflammatory spondylopathies 573.9 Unspecified disorder of liver (12/98) 720.9 Unspecified inflammatory spondylopathy 579.0 Celiac disease 721.0 Cervical spondylosis with w/o myelopathy 579.2 Blind loop syndrome 721.1 Cervical spondylosis with myelopathy 579.3 Other and unspecified postsurgical nonabsorption 721.2 Thoracic spondylosis w/o myelopathy 579.8 Other specified intestinal malabsorption 721.3 Lumbosacral spondylosis w/o melopathy 579.9 Unspecified intestinal malabsorption 721.41-721.42 Thoracic spondylosis without melopathy 585 Chronic renal failure 725 Polymalgia rheumatica 586 Renal failure, unspecified 727.00 Synovitis and tenosynovitis, unspecified 608.3 Atrophy of testis 727.01 Synovitis and tenosynovitis in diseases classified elsewhere 648.20-648.24 Anemia in pregnancy, childbirth or puerperium 727.04 Radial styloid tenosynovitis 713.0 Arthropathy associated with other endocrine and metabolic disorders; code first 727.05 Other tenosynovitis of hand and wrist underlying disease as hemochromatosis (275.0) 727.06 Tenosynovitis of foot and ankle 790.4 Nonspecific elevation of levels of transaminase or LDH (use for elevated Lefts) 727.09 Other synovitis and tenosynovitis 790.6 Other abnormal blood chemistry, iron 727.2 Specific bursitides often of occupational origin 964.0 Poisoning by iron and its compounds (iron overdose) 727.3 Other bursitis 999.8 Other transfusion reaction 729.0 Rheumatism, unspecified and fibrositis V56.0 Extracorporeal dialysis 729.1 Myalgia and myositis, unspecified V56.8 Other dialysis 729.2 Neuralgia, neuritis, and radiculitis, unspecified V58.69 Long term (current) use of other (high risk) medications 730.00-730.09 Acute osteomyelitis 730.10-730.19 Chronic osteomyelitis 730.20-730.29 Unspecified osteomyelitis 730.30-730.39 Periostitis w/o mention of ostoemyelitis 733.00 Osteoporosis, unspecified 733.01 Senile osteoporosis 733.02 Idiopathic osteoporosis 780.6 Pyrexia of unknown origin 782.1 Rash and other non-specific skin eruption 784.0 Headache 790.1 Elevated sedimentation rate 995.2 Unspecified adverse effect of drug, medicinal and biological substance V67.51 Following treatment with high-risk medication

92 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON B

SERUM POTASSIUM 042 Human immunodeficiency virus (HIV) disease 054.10-054.19 Herpes simplex, genital herpes Medicare B Medical Policy April 1, 1999 078.0-078.19 Other diseases due to viruses and Chlamydia 090.0-090.9 Congenital syphilis CPT: 84132 091.0-091.9 Early syphilis symptomatic 092.0-092.9 Early syphilis, latent 250-00-250.93 Diabetes mellitus 093.0-093.9 Cardiovascular syphilis 251.0-251.9 Other disorders of pancreatic internal secretion 094.0-094.9 Neurosyphilis 252.0-252.9 Disorders of parathyroid gland 095.0-095.9 Other forms of late syphilis, with symptoms 253.0-253.9 Disorders of the pituitary gland and its hypothalamic control 096 Late syphilis, latent 254.0-254.9 Diseases of thymus gland 097.0-097.9 Other and unspecified syphilis 255.0-255.9 Disorders of adrenal glands 098.0-098.89 Gonococcal infections 259.0-259.9 Other endocrine disorders 099.0-099.9 Other venereal diseases 263.9 Unspecified protein-calorie malnutrition 104.0 Non-venereal endemic syphilis 276.0-276.9 Disorders of fluid, electrolyte and acid-base balance 131.00-131.9 Trichomoniasis 277.00-277.01 Cystic fibrosis 331.0 Alzheimer’s disease 359.3 Familial periodic paralysis 331.2 Senile degeneration of brain 401.0-401.9 Essential hypertension 356.0 Hereditary peripheral neuropathy 402.00-402.91 Hypertensive heart disease 356.9 Unspecified hereditary and idiopathic peripheral neuropathy 403.00-403.91 Hypertensive renal disease 363.00-363.35 Choroid involvement 404.00-404.93 Hypertensive heart and renal disease 364.00-364.3 Iris involvement 405.01-405.99 Secondary hypertension 364.70-364.74 Iris involvement 410.00-410.92 Acute myocardial infraction 370.50-370.64 Cornea involvement 426.0-426.9 Conduction disorders 379.00-379.09 Scleral involvement 427.0-427.9 Cardiac dysrhythmias 569.41 Rectal ulcer 428.0 Heart failure 607.89 Penile ulcer 560.0-560.9 Intestinal obstruction without mention of hernia 614.0-614.9 Inflammatory disease of ovary, fallopian tube, pelvic organs and tissues 580.0-580.9 Acute glomerulonephritis 615.0-615.9 Inflammatory diseases of uterus, except cervix 581.0-581.9 Nephrotic syndrome 616.0-616.9 Inflammatory disease of cervix, vagina and vulva 582.0-582.9 Chronic glomerulonephritis 692.9 Dermatoses, unspecified 583.0-583.9 Nephritis and nephropathy, not specified as acute or chronic 696.3 Pityriasis rosea 584.5-584.9 Acute renal failure 704.00-704.01 Alopecia 585 Chronic renal failure 760.2 Maternal infections 586 Renal failure, unspecified V01.6 Contact with or exposure to venereal diseases 587 Renal sclerosis, unspecified 588.0-588.9 Disorders resulting from impaired renal function 589.0-589.9 Small kidney of unknown cause THYROID TESTING INCLUDING TSH 729.82 Other musculoskeltal systems referable to limbs, cramps Medicare B Medicare Policy June 1, 1999 780.71-780.79 Malaise and fatigue 787.01 Nausea with vomiting CPT: 84436 Thyroxine, total 787.03 Vomiting CPT: 84439 Thyroxine, free 787.91 Diarrhea CPT: 84443 Thyroid stimulating hormone (TSH) 790.6 Other abnormal blood chemistry CPT: 84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding 925.1-929.9 Crushing injury ratio (THBR) 941.20-941.59 Burn of face, head and neck CPT: 80091 Thyroid panel, includes Thyroxine; total (84436) and Triiodothyro- 942.20-942.59 Burn of trunk nine (T-3), resin uptake (84479) (Deleted 4/1/2000) 943.20-943.59 Burn of upper limb, except wrist and hand CPT: 80092 Thyroid panel with thyroid stimulating hormone (TSH) (84443) 945.20-945.59 Burn of lower limb and includes (84436, 84479) (Deleted 4/1/2000) 946.2-946.5 Burns of multiple specified sites 947.1-947.9 Burn of internal organs 193 Malignant neoplasm of thyroid gland 948.10-948.99 Burns classified according to extent of body surface involved 198.82 Secondary malignant neoplasm, genital organs 949.2-949.5 Burn, unspecified 198.89 974.4 Poisoning by other diuretics 226 Benign neoplasm of thyroid glands 994.2 Effects of hunger 227.3 Benign neoplasm of pituitary gland and craniopharyngeal duct (pouch) 995.2 Unspecified adverse effect of drug, medicinal and biological substance 234.8 Carcinoma in situ of other specified sites V58.1 Chemotherapy 237.4 Neoplasm of uncertain behavior, other and unspecified endocrine glands V58.69 Long term (current) use of other medications 239.7 Neoplasm of unspecified nature, endocrine glands and other parts of nervous V67.51 Follow-up examination following completed treatment with high-risk medication system 240.0-240.9 Goiter simple and unspecified 241.0-241.9 Non-toxic nodular goiter SYPHILIS TEST (RPR) 242.00-242.91 Toxic diffuse goiter; with or without mention of thyrotoxic crisis or storm Medicare B Medical Policy May 1, 1998 243 Congenital hypothyroidism 244.0-244.9 Acquired hypothyroidism CPT: 86592 Syphilis test qualitative (e.g., VDRL, RPR, ART) 245.0-245.9 Thyroiditis CPT: 86593 quantitative 246.1-246.3 Dyshormonogenic goiter; Cyst of thyroid; Hemorrhage and infarction of thyroid CPT: 86781 Treponema Pallidum, confirmatory test (e.g., FTA-abs) 246.8 Other specified disorders of the thyroid 252.1 Hypoparathyroidism

SEPTEMBER 2000 93 LMRPs WASHINGTON B (509) 927-6250 • 1-800-433-1583

253.1 Other and unspecified anterior pituitary hyperfunction 703.8 Other specified diseases of nail (brittle nail) 253.2 Panhypopituitarism 704.00 Alopecia, unspecified 253.3-253.4 Pituitary dwarfism and other anterior pituitary disorders 729.1 Myalgia and myositis, unspecified 253.7 latrogenic pituitary disorder 729.82 Cramp of limb (muscle cramp) 255.2 Adrenogeniral disorders 733.09 Osteoporosis, drug induce 255.3 Other corticoadrenal overactivity 750.15 Macroglossia 255.4 Corticoadrenal insufficiency 759.2 Anomalies of other endocrine glands 258.0-258.9 Polyglandular dysfunction and related disorders 775.3 Neonatal thyrotoxicosis 266.0 Ariboflavinosis 780.09 Alteration of consciousness 272.0-272.2 Pure hypercholesterolemia; Pure hyperglyceridemia; Mixed hyperlipidemia 780.51 Insomnia with sleep apnea 272.4 Other and unspecified hyperlipidemia 780.53 Hypersomnia with sleep apnea 275.40-275.49 Disorders of calcium metabolism; mineral metabolism 780.57 Other and unspecified sleep apnea 276.1 Hyperosmolality and/or hyponatremia 780.79 Malaise and fatigue 278.00 Obesity, unspecified 780.8 Hyperhidrosis 278.01 Morbid obesity 780.9 Other general symptoms 290.0-290.3 Senile and presenile organic psychotic conditions 781.0 Abnormal involuntary movements 293.1 Subacute delirium 781.3 Lack of coordination, ataxia 294.0-294.9 Chronic organic psychotic conditions 782.8 Changes in skin texture 295.00-295.95 Schizophrenic disorders 783.1 Abnormal weight gain 296.00-296.99 Affective psychosis 783.2 Abnormal loss of weight 296.7 Bipolar affective disorder, unspecified 784.1 Throat pain 297.1 Paranoia 784.49 Voice disturbance; other 298.8 Other and unspecified reactive psychosis 785.0-785.1 Symptoms involving cardiovascular system; tachycardia, unspecified;palpitations 300.00-300.02 Anxiety states 787.2 Dysphagia 300.81 Somatization disorder 787.99 Change in bowel habits 307.1 Anorexia nervosa 790.6 Other abnormal blood chemistry, lithium 307.50 Eating disorder, unspecified 793.2 Nonspecific abnormal findings on radiological and other examination of body 307.51 Bulimia structure; other intrathoracic organ 310.1 Organic personality syndrome 794.5 Thyroid, abnormal scan or uptake 311 Depressive disorder, not elsewhere classified 799.2 Nervousness 331.0-331.2 Alzheimer’s; Pick’s disease; Senile degeneration of brain 990 Effects of radiation, unspecified 333.1 Essential and other specified forms of tremor 995.2 Unspecified adverse effect of drug (to monitor Lithium effect on thyroid function) 333.5 Other choreas 354.0 Carpal tunnel syndrome TROPONIN 356.9 Hereditary and idiopathic peripheral neuropathy, unspecified 357.8 Other polyneuropathy Medicare B Medical Policy August 1, 1998 358.1 Myasthenci syndromes in diseases classified elsewhere 359.5 Myopathy in endocrine diseases classified elsewhere CPT: 84484 Troponin, Quantitative 368.2 Diplopia CPT: 84512 Troponin, Qualitative 374.41 Lid retraction or lag 376.21 Thyrotoxic exophthalmos 410.00-411.89 Acute Myocardial Infarction 376.22 Exophthalmic ophthalmoplegia 413.0-413.9 Unstable Angina 376.30-376.31 Exophthalmos: unspecified and constant 422.0-422.93 Acute Myocarditis 376.33-376.34 Orbital edema or congestion, intermittent exophthalmos 427.0-427.81 Cardiac Arrhythmias 423.9 Other diseases of pericardium; unspecified diseases of the pericardium 427.9 Cardiac Dysrhythmia 425.7 Nutritional and metabolic cardiomyopathy 428.0 Congestive Heart Failure 427.0 Paroxysmal supraventricular tachycardia 785.51 Cardiogenic Shock 427.2 Paroxysmal tachycardia, unspecified 786.50-786.59 Acute Chest Pain 427.31 Atrial fibrillation 794.31 Abnormal Electrocardiogram (ECG) (EKG) 427.89 Other specified cardiac dysrhythmias 861.00-861.01 Injury to Heart 427.9 Cardiac dysrhythmia, unspecified 922.1 Chest Wall Contusion 428.0 Congestive heart failure 428.1 Left heart failure 429.2 Cardiovascular disease, unspecified 429.3 Cardiomegaly 560.1 Paralytic ileus 564.0 Constipation 564.7 Megacolon, other than Hirschsprung’s 611.1 Other disorders of breast; hypertrophy of breast 611.6 Galactorrhea not associated with childbirth 625.3 Dysmenorrhea 626.0-626.2 Absence of menstruation; Scanty or infrequent menstruation; Excessive or frequent menstruation 648.10-648.14 Other current conditions in the mother, classifiable elsewhere, but complicating pregnancy, childbirth or puerperium - Thyroid dysfunction 676.20-676.24 Engorgement of breast associated with childbirth and disorders of lactation 701.1 Keratoderma, acquired (dry skin)

94 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON B

IMMUNOASSAY FOR TUMOR ANTIGEN 175.0-175.9 Malignant neoplasm of male breast 198.81 Secondary malignant neoplasm, breast Medicare B Medical Policy May 1, 1999 V10.3 Personal history of malignant neoplasm of breast

CPT: 82105 Alpha Fetoprotein CPT: 86316 CA 15-3

070.22-070.23 Viral hepatitis B with hepatic coma, chronic, with or without mention of hepatitis 174.0-174.9 Malignant neoplasm of female breast delta 175.0-175.9 Malignant neoplasm of male breast 070.32-070.33 Chronic viral hepatitis B without mention of hepatic coma, with or without 198.81 Secondary malignant neoplasm, breast mention of hepatitis delta 238.3 Neoplasm of uncertain behavior of breast 070.44 Chronic hepatitis C with hepatic coma 239.3 Neoplasm of uncertain nature, breast 070.54 Chronic hepatitis C without mention of hepatic coma V10.3 Personal history of malignant neoplasm of breast 155.0-155.2 Malignant neoplasm of liver and intrahepatic bile ducts 164.2 Malignant neoplasm of anterior mediastinum URINALYSIS (UA) 164.3 Malignant neoplasm of posterior mediastinum 183.0 Malignant neoplasm, ovary Medicare B Medical Policy May 1, 1999 186.0-186.9 Malignant neoplasm of testis 197.7 Secondary malignant neoplasm of liver, specified as secondary CPT: 81000 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, 198.6 Secondary malignant neoplasm of ovary hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific 198.82 Secondary malignant neoplasm, genital organs gravity, urobilinogen, any number of these constituents; with 235.3 Neoplasm of uncertain behavior of liver and biliary passages microscopy 235.4 Neoplasm of uncertain behavior of retroperitoneum and peritoneum CPT: 81001 Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, 571.40 Chronic hepatitis, unspecified hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific 571.41 Chronic persistent hepatitis gravity, urobilinogen, any number of these constituents; with 571.49 Other, chronic hepatitis microscopy 789.1 Hepatomegaly CPT: 81002 without microscopy, non-automated V10.43 Personal history of malignant neoplasm, ovary CPT: 81003 without microscopy, automated V10.47 Personal history of malignant neoplasm, testis CPT: 81005 Urinalysis; qualitative or semiquantitative, except immunoassays V10.48 Personal history of malignant neoplasm, genital organs epididymis CPT: 81007 bacteria screen, by non-culture technique, commercial kit (specify type) CPT: 84702 HCG Quantitative CPT: 81015 microscopic only CPT: 84703 HCG Qualitative 016.00 - 016.06 Tuberculosis of kidney 164.2 Malignant neoplasm of anterior mediastinum 016.10 - 016.16 Tuberculosis of bladder 164.3 Malignant neoplasm of posterior mediastinum 016.20 - 016.26 Tuberculosis of ureter 181 Malignant neoplasm of placenta 016.30 - 016.36 Tuberculosis of other urinary organs 183.0 Malignant neoplasm, ovary 016.40 - 016.46 Tuberculosis of epididmysis 186.0 Malignant neoplasm of undescended testis 016.50 - 016.56 Tuberculosis of male genital organs 186.9 Malignant neoplasm, other and unspecified testis 016.60 - 016.66 Tuberculosis of oophoritis and salpingitis 187.8 Malignant neoplasm of other specified sites of male genital organs 016.70 - 016.76 Tuberculosis of female genital organs 187.9 Malignant neoplasm of male genital organs, site unspecified 016.90 - 016.96 Genitourinary, tuberculosis, unspecified 198.82 Secondary malignant neoplasm, genital organs 038.0 - 038.9 Septicemia 611.1 Hypertrophy of breast; gynecomastia 054.10 Genital herpes, unspecified 626.0 Amenorrhea 054.11 Herpetic vulvovaginitis 633.0-633.9 Ectopic Pregnancy 054.12 Herpetic ulceration of the vulva 634.00-634.91 Abortions 054.13 Herpetic infection of penis V10.43 Personal history of malignant neoplasm, ovary 054.19 Genital herpes, other V10.47 Personal history of malignant neoplasm, testis 070.0 - 070.1 Viral hepatitis, acute, with/without hepatic coma V71.1 Observation for suspected malignant neoplasm 070.20 - 070.23 Viral hepatitis B with hepatic coma 070.30 - 070.33 Viral hepatitis B without mention of hepatic coma CPT: 86316 CA125 070.41 - 070.49 Other specified viral hepatitis with hepatic coma 070.51 - 070.59 Other specified viral hepatitis without mention of hepatic coma 158.8 Malignant neoplasm of specific parts of peritoneum 072.0 Mumps orchitis 158.9 Malignant neoplasm of peritoneum, unspecified 078.11 Condyloma acuminatum 182.0-182.8 Malignant neoplasm of body of uterus 078.88 Other specified diseases due to chlamydia 183.0-183.9 Malignant neoplasm of the ovary and other uterine adnexa 079.81 - 079.89 Other specified viral and chlamydial infection 198.6 Secondary malignant neoplasm of ovary 079.98 Unspecified chlamydial infection 236.1 Neoplasm of uncertain behavior of placenta 087.0 - 087.1 Relapsing fever 236.2 Neoplasm of uncertain behavior of ovary 095.4 Syphilis of kidney 236.3 Neoplasm of uncertain behavior of other female genital organs 098.0 Gonococcal infection, acute, lower genitourinary tract 236.4 Neoplasm of uncertain behavior of testis 098.10 - 098.19 Gonococcal infection, acute, upper genitourinary tract 236.6 Neoplams of uncertain behavior of other and unspecified male genital organs 098.2 Gonococcal infection, chronic, of lower genitourinary tract V10.43 Personal history of malignant neoplasm, ovary 098.30 - 098.39 Gonococcal infection, chronic, of upper genitourinary tract 098.89 Other Gonococcal infection of other specified sites CPT: 86316 CA 27.29 099.3 Reiter’s disease 099.40 - 099.41 Nonspecified urethritis 174.0-174.9 Malignant neoplasm of female breast 099.53 - 099.54 Other venereal diseases due to Chlamydia trachomatis

SEPTEMBER 2000 95 LMRPs WASHINGTON B (509) 927-6250 • 1-800-433-1583

100.0 Leptospiral icterohemorrhagica 573.0 - 573.3 Other disorders of liver 102.0 - 102.9 Yaws 580.0 - 580.4 Acute glomerulonephritis 112.1 Candidasis of vulva and vagina 580.81 - 580.89 Acute glomerulonephritis with other specifies pathological lesion in kidney 125.0 - 125.1 Filarial infection and dracontiasis 580.9 Acute glomerulonephritis with unspecified pathological lesion in kidney 131.00-131.03 Urogenital trichomoniasis 581.0 - 581.3 Nephrotic syndrome 185 Malignant neoplasm of prostate 581.81 - 581.89 Nephrotic syndrome with other specific pathological lesion in kidney 186.0 - 186.9 Malignant neoplasm of testis 581.9 Nephrotic syndrome with unspecified pathological lesion in kidney 188.0 - 188.9 Malignant neoplasm of bladder 582.0 - 582.4 Chronic glomerulonephritis 189.0 - 189.9 Malignant neoplasm of kidney and other and unspecified urinary organs 582.81 - 582.89 Chronic glomerulonephritis with other specified pathological lesion in kidney 198.0 - 198.1 Secondary malignant neoplasm of kidney and other urinary organs 582.9 Chronic glomerulonephritis with unspecified pathological lesion in kidney 222.2 Benign neoplasm of prostate 583.0 - 583.7 Nephritis and nephropathy, not specified as acute or chronic 223.0 - 223.3 Benign neoplasm of kidney and other urinary organs 583.81 - 583.89 Specified and other nephritis and nephropathy 223.81 - 223.89 Benign neoplasm of urethra and other urinary organs 583.9 Nephritis and nephropathy with unspecified pathological lesion in kidney 233.4 Carcinoma in situ of prostate 584.5 - 584.9 Acute renal failure 233.7 Carcinoma in situ of bladder 585 Chronic renal failure 233.9 Carcinoma in situ and other unspecified urinary organs 586 Renal failure, unspecified 236.5 Neoplasm of uncertain behavior of prostate 588.1 - 588.8 Disorders resulting from impaired renal function 236.7 Neoplasm of uncertain behavior of bladder 590.00 - 590.01 Chronic pyelonephritis 236.90 - 236.99 Neoplasm of uncertain behavior of other and unspecified urinary organs 590.10 - 590.11 Acute pyelonephritis 250.00 - 250.03 Diseases of other endocrine glands, diabetes mellitus without complication 590.2 - 590.3 Renal and perinephric abcess/pyeloureteritus 250.10 - 250.13 Diabetes with ketoacidosis 590.80 - 590.81 Other pyelonephritis or pyonephrosis, not specified as acute or chronic 250.20 - 250.23 Diabetes with hyperosmolarity 590.9 Infection of kidney, unspecified 250.30 - 250.33 Diabetes with other comas 591 Hydronephrosis 250.40 - 250.43 Diabetes with renal manifestations 592.0 - 592.9 Calculus of kidney and ureter 250.50 - 250.53 Diabetes with ophthalmic manifestations 593.0 - 593.6 Other disorders of kidney and ureter 250.60 - 250.63 Diabetes with neurological manifestations 593.70 - 593.73 Vesicoureteral reflux 250.70 - 250.73 Diabetes with peripheral circulatory disorders 593.81 - 593.89 Other specified disorders of kidney and ureter 250.80 - 250.83 Diabetes with other specified manifestations 593.9 Unspecified disorder of kidney and ureter 250.90 - 250.93 Diabetes with unspecified complications 594.0 - 594.9 Calculus of lower urinary tract 253.5 - 253.6 Diabetes insipidus and other disorders of neurohypophysis 595.0 - 595.4 Cystitis 271.4 Renal glycosuria 595.81 - 595.89 Other specified types of cystitis 272.2 - 272.4 Mixed and other unspecified hyperlipidemia 595.9 Cystitis unspecified 273.0 - 273.8 Disorders of plasma protein metabolism 596.0 - 596.4 Other disorders of bladder 274.10 - 274.19 Gouty nephropathy 596.51 - 596.59 Other functional disorders of bladder 275.0 Disorders of iron metabolism 596.6 - 596.9 Rupture of bladder, nontraumatic; hemorrhage into bladder wall; other specified 275.42 Hypercalcemia disorders of bladder 276.0 - 276.6 Disorders of fluid, electrolyte and acid-base balance 597.0 Urethral abcess 277.3 - 277.4 Amyloidosis/disorders of bilirubin excretion 597.80 - 597.89 Other and unspecified urethritis 282.60-282.69 Sickle-cell anemia 598.00 - 598.01 Urethral stricture due to infection 283.11 Hemolytic-uremic syndrome 598.1 - 598.9 Urethral stricture 306.53 Psychogenic Dysuria 599.0 - 599.7 Other disorders of urethra and urinary tract 344.61 Cauda equina syndrome with neurogenic bladder 599.81 - 599.89 Other specified disorders of urethra and urinary tract 401.0 - 401.1 Essential hypertension 599.9 Unspecified disorders of urethra and urinary tract 402.00 - 402.01 Malignant hypertensive heart disease, with/without congestive heart failure 600 Hyperplasia of prostate 402.10 - 402.11 Benign hypertensive heart disease, with/without congestive heart failure 601.0 - 601.9 Inflammatory diseases of prostate 402.90 - 402.91 Unspecified hypertensive heart disease, with/without congestive heart failure 602.0 - 602.9 Other disorders of prostate 403.00 - 403.01 Malignant hypertensive renal disease 603.0 - 603.9 Hydrocele 403.10 - 403.11 Benign hypertensive renal disease 604.0 Orchitis and epididymitis 403.90 - 403.91 Unspecified hypertensive renal disease 604.90 - 604.91 Other orchitis, epididymitis and epididymoorchitis, without me ntion of abscess 404.00 - 404.03 Malignant hypertensive heart and renal disease 605 Redundant prepuce and phimosis 404.10 - 404.13 Benign hypertensive heart and renal disease 606.1 Oligospermia 404.90 - 404.93 Unspecified hypertensive and renal disease 606.9 Male infertility, unspecified 405.01 - 405.09 Malignant secondary hypertension 607.1 Balanoposthitis 405.11 - 405.19 Benign secondary hypertension 607.81 Balanitis xerotica obliterans 405.91 - 405.99 Unspecified secondary hypertension 607.84 Impotence of organic origin 421.0 - 421.9 Acute and subacute endocarditis 607.89 Other specified disorders of penis 428.0 Congestive heart failure 608.1 Spermatocele 446.0 - 446.1 Polyarteritis nodosa and allied conditions 608.2 Torsion of testis 446.20 - 446.29 Hypersensitivity angiitis 608.83 Vascular disorders of male genital organs 446.3 - 446.7 Polyarteritis nodosa and allied conditions 608.89 Other disorders of male genital organs 447.3 - 447.6 Other disorders of arteries and arterioles 608.9 Unspecified disorders of male genital organs 456.4 Scrotal varices (varicocele) 616.10 - 616.11 Vaginitis and vulvovaginitis 457.0 - 457.1 Postmastectomy lymphedema and other lymphedema 618.0 Genital prolapse 570 Acute and subacute necrosis of liver 619.0 - 619.9 Fistula involving female genital tract 571.40 - 571.49 Chronic hepatitis 625.0 Dyspareunia 571.5 - 571.8 Chronic and other cirrhosis of the liver 625.6 Stress incontinence, female 572.2 Hepatic coma 625.9 Unspecified symptom associated with female genital organs

96 SEPTEMBER 2000 (509) 927-6250 • 1-800-433-1583 LMRPs WASHINGTON B

628.9 Infertility, female of unspecified origin 926.11 - 926.19 Crushing injury of other specified sites 634.00 - 634.02 Spontaneous abortion complicated by genital tract and pelvic infection 926.8 Crushing injury to multiple sites of trunk 634.30 - 634.32 Spontaneous abortion complicated by renal failure 939.0 Foreign body in genitourinary tract, bladder and urethra 635.00 - 635.02 Legally induced abortion complicated by genital tract and pelvic infection 958.5 Traumatic anuria 635.30 - 635.32 Legally induced abortion omplicated by renal failure 959.1 Injury, trunk 636.00 - 636.02 Illegally induced abortion complicated by genital tract and pelvic infection 961.2 Poisoning by heavy metal anti-infectives 636.30 - 636.32 Illegally induced abortion complicated by renal failure 963.1 Poisoning by antineoplastic and immuno-suppressive drugs 637.00 - 637.02 Unspecified abortion complicated by genital tract and pelvic infection 963.3 Poisoning by alkalizing agents 637.30 - 637.32 Unspecified abortion complicated by renal failure 965.1 Poisoning by salicylates 638.00 - 638.02 Failed attempted abortion complicated by genital tract and pelvic infection 992.0 - 992.8 Effects of heat and light 638.30 - 638.32 Failed attempted abortion complicated by renal failure 995.2 Unspecified adverse effect of drug, medicinal and biological substance 642.00 - 642.04 Benign essential hypertension complicating pregnancy, childbirth and the 996.30 - 996.39 Mechanical complication of genitourinary device, implant and g raft puerperium 996.64 - 996.65 Infection and inflammatory reaction due to internal prosthetic device, implant and 642.10 - 642.14 Hypertension secondary to renal disease, complicating pregnancy, childbirth and graft the puerperium 996.81 Complications of transplanted kidney 642.20 - 642.24 Other pre-existing hypertension complicating pregnancy, childbirth and the 997.5 Urinary complications puerperium 998.2 Accidental puncture or laceration during a procedure 642.30 - 634.34 Transient hypertension complicating pregnancy, childbirth and the puerperium 999.8 Complications of medical care, not elsewhere classified; other transfusion 642.40 - 642.44 Hypertension complicating pregnancy, mild or unspecified pre-eclampsia reaction 642.50 - 642.54 Hypertension complicating pregnancy, severe pre-eclampsia V10.46 Personal history of malignant neoplasm of prostate 642.60 - 642.64 Hypertension complicating pregnancy, eclampsia V10.50-V10.59 Personal history of malignant neoplasm urinary organs 642.70 - 642.74 Hypertension complicating pregnancy, pre-eclampsia or eclampsia superimposed V13.00-V13.09 Personal history of other diseases urinary system on pre-existing hypertension V15.5 Injury 642.90 - 642.94 Unspecified hypertension complicating pregnancy, childbirth and the puerperium V21.0-V21.9 Constitutional states in development 646.60 - 646.64 Infection of genitourinary tract in pregnancy V22.0 - V22.2 Normal pregnancy 647.10 - 647.14 Infections and parasitic conditions in mother, Gonorrhea V23.0 - V23.7 Supervision of high-risk pregnancy 648.00 - 648.04 Other current conditions in mother, Diabetes mellitus V23.81- 23.89 Other high risk pregnancy 648.80 - 648.84 Other abnormalities in shape or position of gravid uterus and of neighboring V23.9 Unspecified high-risk pregnancy structures V42.0 Persons with organs or tissue replaced by kidney transplant 669.30 - 669.34 Acute renal failure following labor and delivery V44.50-V44.59 Persons with cystostomy 672.00 - 672.04 Pyrexia of unknown origin during the puerperium V44.6 Persons with other artificial opening of urinary tract 710.0 - 710.4 Diffuse diseases of connective tissue V45.1 Renal dialysis status 710.9 Unspecified diffuse connective tissue disease V58.0 Radiotherapy 711.00 - 711.09 Pyogenic arthritis V58.69 Long term (current) use of other medications 714.0-714.9 Rheumatoid arthritis V67.51 Following completed treatment with high-risk medication, NEC 719.40 - 719.49 Pain in joint 724.2 Lumbago 724.5 Backache, unspecified 752.51 Undescended testis 753.0 Renal agenesis and dysgenesis 753.10 - 753.19 Cystic kidney disease 753.20 - 753.29 Obstructive defects of renal pelvis and ureter 753.3 - 753.9 Other anomalies of urinary system 780.6 Fever; fever of unknown origin (FUO) 785.59 Other shock without mention of trauma 788.0 - 788.1 Renal colic/dysuria 788.20 - 788.29 Retention of urine 788.30 - 788.39 Incontinence of urine 788.41 - 788.43 Frequency of urination and polyuria 7 788.5 Oliguria and anuria 788.61 - 788.69 Other abnormality of urination 788.7 - 788.9 Urethral discharge/extravasation of urine/ other symptoms involving urinary system 789.00 - 789.99 Other symptoms involving abdomen and pelvis 790.7 Bacteremia 790.93 Elevated PSA 791.0 - 791.9 Nonspecific findings on examination of urine 793.5 - 793.6 Abnormal findings on radiological and other examinations of genitourinary organs, abdominal area, including retroperitoneum 796.2 Elevated blood pressure reading without diagnosis of hypertension 866.00 - 866.13 Injury to kidney 867.0 - 867.3 Injury to bladder and urethra 867.6 Injury to other specified pelvic organs, without mention of open wound into cavity 922.1 - 922.33 Contusion of trunk 922.4 Contusion to genital organs 926.0 Crushing injury of external genitalia

SEPTEMBER 2000 97 LMRPs WASHINGTON B (509) 927-6250 • 1-800-433-1583

98 SEPTEMBER 2000