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Medicare Part B - Noridian Lcds MMEEDDIICCAARREE NATIONAL & LOCAL COVERAGE DETERMINATIONS REFERENCE MANUAL CMS NCDs October 2012 Medicare Part B - Noridian LCDs Easy Policy Access – Click “Bookmark Tab” on left side of page…. Click on Individual LCD/NCD Quick Reference: Lab Testing Covered Under NCD or LCD (South Dakota Part B November 2011) NCD (Black) or LCD (Blue) Name Common Name or Abbrev. CPT Code CPT Descriptor Alpha-fetoprotein AFP 82105 Alpha-fetoprotein; serum Blood Counts Blood smear exam 85007 Blood count; blood smear, microscopic examination with manual differential WBC count Blood Counts Blood smear exam 85008 Blood count; blood smear, microscopic examination without manual differential WBC count Blood Counts CBC (without diff) 85027 Blood count, complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet ) Blood Counts CBC with diff 85025 Blood count, complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count Blood Counts Hematocrit/ HCT 85014 Blood count, hematocrit (Hct) Blood Counts Hemoglobing/ HGB 85018 Blood count, Hemoglobin Blood Counts Manual cell counts 85032 Blood count; manual cell count (erythrocyte, leukocyte, or platelet) each Blood Counts Platelet 85049 Blood count; platelet, automated Blood Counts Spun microhematocrit 85013 Blood count, Spun microhematocrit Blood Counts WBC 85048 Blood count, leukocyte (WBC), automated Blood Counts WBC differential 85004 Blood count, automated differential white blood cell (WBC) count BNP BNP 83880 Natiuretic Peptide CA 125 Tumor Antigen CA 125 86304 Immunoassay for tumor antigen, quantitative, CA 125 CA 15-3 & CA 27.29 Tumor Antigens CA 15-3 & CA 27.29 86300 Immunoassay for tumor antigen, quantitative; CA 15-3 CA 27.29 CA 19-9 Tumor Antigen CA 19-9 86301 Immunoassay for tumor antigen, quantitative; CA 19-9 Carcinoembryonic Antigen CEA 82378 Carcinoembryonic antigen (CEA) Collagen Crosslinks Collagen crosslinks 82523 Collagen cross links, any method Cytogenetics Testing - LDC Cytogenetics / Chromosome Multiple 88272/88273/88274/88275 – Cytogentics multiple 3-300; 88280 Chromosome karyotyping; studies 88283 Chromosome banding; 88285 Chromosome count additional; 88289 Chromosome study additional; 88291 Cyto/molecular report; 88299 Cytogenetic study Digoxin Digoxin 80162 Digoxin (Therapeutic Drug Assay) Fecal Occult Blood Occult Blood 82272 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, single specimen (eg, from digital rectal exam) Fecal Occult Blood Occult Blood G0394 Blood occult test (e.g., guaiac), feces, for single determination for colorectal neoplasm (e.g., patient provided 3 cards or 1 triple card for consecutive collection) Gamma Glutamyl Transferase GGT 82977 Glutamyltransferase, gamma (GGT) Genetic Testing - LCD Molecular Testing Multiple Types – Multiple 83890 Molecular diag isolation/extraction; 83891 Molecular diag isolation/extraction of purify. Examples : Factor V Leiden, Nuc. Acid; 83892 Molecular diag enzymatic digestion; 83893 Molecular diag DOT/BLOT Hemachromatosis, Factor 2, production; 83894 Molecular diag separation by gel electrophoresis; 83898 Molecular diag Prothrom Nuc, PCR Methods amplification; 83904 Molecular diag mutation identification; 83912 Molecular diag interp and report Glucose Testing Glucose 82947 Glucose; quantitative, blood (except reagent strip) Glucose Testing Glucose Home Device 82962 Glucose, blood by glucose monitoring device(s) FDA specifically for home use. Glucose Testing Glucose POC 82948 Glucose; blood, reagent strip Glycated Hemoglobin/ Glycated Protein Glycated Protein 82985 Glycated protein Glycated Hemoglobin/ Glycated Protein Hemoglobin A1c / Hgb A1c 83036 Hemoglobin; glycated Hepatitis Panel/Acute Hepatitis Panel Hepatitis Panel 80074 Acute Hepatitis Panel NCD (Black) or LCD (Blue) Name Common Name or Abbrev. CPT Code CPT Descriptor HIV Testing Diagnosis HIV 1 86701 Qualitative or semiquantitative immunoassays performed by multiple step methods; HIV-1 HIV Testing Diagnosis HIV 1 87390 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; HIV-1 HIV Testing Diagnosis HIV 1& 2 / HIV 86703 Qualitative or semiquantitative immunoassays performed by multiple step methods; HIV-1 and HIV-2, single assay HIV Testing Diagnosis HIV 2 86702 Qualitative or semiquantitative immunoassays performed by multiple step methods; HIV-2 HIV Testing Diagnosis HIV 2 87391 Infectious agent antigen detection by enzyme immunoassay technique, qualitative or semiquantitative, multiple step method; HIV-2 HIV Testing Diagnosis HIV by PCR 87534 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, direct probe HIV Testing Diagnosis HIV Western Blot 86689 Qualitative or semiquantitative immunoassays performed by multiple step methods; HTLV or HIV antibody, confirmatory test (for example, Western Blot) HIV Testing Prognosis/Monitoring HIV viral load or quantification 87536 Infectious agent detection by nucleic acid (DNA or RNA); HIV-1, quantification HIV Testing Prognosis/Monitoring HIV viral load/ HIV quantification 87539 Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, quantification Human Chorionic Gonadotropin HCG, Quantitative 84702 Gonadotropin, chorionic (hCG); quantitative Iron Studies Ferritin 82728 Ferritin Iron Studies Iron 83540 Iron Iron Studies Iron Binding Capacity / IBC 83550 Iron Binding capacity Iron Studies Transferrin 84466 Transferrin Lipid Testing Cholesterol 82465 Cholesterol, serum or whole blood, total Lipid Testing HDL Cholesterol 83718 Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol) Lipid Testing LDL Cholesterol Direct 83721 Lipoprotein, direct measurement, LDL cholesterol Lipid Testing Lipid Panel 80061 Lipid panel Lipid Testing Lipoprotein electrophoresis 83700 Lipoprotein, blood; electrophoretic separation and quantitation Lipid Testing Lipoprotein High Resolution 83701 Lipoprotein blood; high resol. fractionation and quantitation of lipoproteins including lipoprotein subclasses when performed (eg, electrophoresis, ultracentrifugation) Lipid Testing Lipoprotein subclasses 83704 Lipoprotein blood; quant. of lipoprotein particle #s & lipoprotein particles subclasses Lipid Testing Triglycerides 84478 Triglycerides Partial Thromboplastin Time PTT / APTT 85730 Thromboplastin time, partial (PTT); plasma or whole blood Prostate Specific Antigen PSA 84153 Prostate Specific Antigen (PSA), total Prothrombin Time Protime / PT 85610 Prothrombin Time Thyroid Testing T3 Uptake/ THBR 84479 Thyroid hormone (T3 or T4) uptake or thyroid hormone binding ratio (THBR) Thyroid Testing T4 84436 Thyroxine (T4); total Thyroid Testing T4, Free 84439 Thyroxine (T4); free Thyroid Testing TSH 84443 Thyroid stimulating hormone (TSH) Urine Culture, Bacterial Kirby Bauer Sensitivity 87184 Susceptibility studies, antimicrobial agent; disk method, per plate (12 or< agents). Urine Culture, Bacterial MIC 87186 Susceptibility studies, antimicrobial agent; microdilution or agar dilution (minimum inhibitory concentration (MIC) or breakpoint), each multi-antimicrobial, per plate. Urine Culture, Bacterial Urine Colony Count 87086 Culture, bacterial; quantitative, colony count, urine. Urine Culture, Bacterial Urine Culture / C&S 87088 Culture, bacterial; with isolation & presumptive identification of each isolates, urine. Vitamin D Vitamin D 25 82306 Vitamin D; 25 Hydroxy Vitamin D Vitamin D 1,25 82652 Vitamin D; 1,25 Dihydroxy QUICK REFERENCE INFORMATION: R Preventive Services Official CMS Information for Medicare Fee-For-Service Providers This educational tool provides information on Medicare preventive services. Information provided includes Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes; International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes; coverage requirements; frequency requirements; and beneficiary liability for each Medicare preventive service. SERVICE HCPCS/CPT CODES ICD-9-CM CODES WHO IS COVERED FREQUENCY BENEFICIARY PAYS Initial Preventive All Medicare beneficiaries whose first G0402: Physical Once in a lifetime G0402 – IPPE Part B coverage began on or after 01/01/05 • Copayment/coinsurance waived Examination (IPPE) G0403 – EKG for IPPE No specific diagnosis code Must furnish no later than Important – The screening EKG is an • Deductible waived Also known as G0404 – EKG tracing for IPPE Contact the local Medicare 12 months after the effective optional service that may be G0403, G0404, and G0405: the “Welcome G0405 – EKG interpret & report Contractor for guidance date of the first Medicare performed as a result of a to Medicare for IPPE Part B coverage • Copayment/coinsurance applies referral from an IPPE Preventive Visit” • Deductible applies All Medicare beneficiaries who are no No specific diagnosis code longer within 12 months after the effective Annual Wellness G0438 – Initial visit • Once in a lifetime for G0438 • Copayment/coinsurance waived date of their first Medicare Part B coverage Visit (AWV) G0439 – Subsequent visit Contact the local Medicare • Annually for G0439 • Deductible waived Contractor for guidance period and who have not received an IPPE or AWV within the past 12 months Medicare beneficiaries with certain risk factors for AAA Ultrasound No specific diagnosis code Screening for G0389 – Ultrasound exam AAA Important – Eligible beneficiaries must • Copayment/coinsurance waived Contact the local Medicare Once in a lifetime Abdominal Aortic screening receive a referral
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