CPT 82306, 82652 - VITAMIN D procedure

CPT/HCPCS Codes

Group 1 Paragraph: N/A

Group 1 Codes:
82306 VITAMIN D; 25 HYDROXY, INCLUDES FRACTION(S), IF PERFORMED
82652 VITAMIN D; 1, 25 DIHYDROXY, INCLUDES FRACTION(S), IF PERFORMED


Coverage Indications, Limitations, and/or Medical Necessity

Vitamin D is a hormone, synthesized by the skin, the liver, and then metabolized by the kidney to an active hormone, calcitriol. An excess of vitamin D may lead to hypercalcemia. Vitamin D deficiency may lead to a variety of disorders. This LCD identifies the indications and limitations of Medicare coverage and reimbursement for these services.

Vitamin D is called a "vitamin" because of its availability from an exogenous source, predominately from oily fish in the form of cholecalciferol, vitamin D3. Plant-based vitamin D is in the form of ergocalciferol, Vitamin D2. It is really a hormone, as it is synthesized by the skin, metabolized by the liver and converted by the kidney to an active hormone, calcitriol. Calcitriol in its classical action, absorbs calcium from the intestine, and promotes bone mineralization.

In the skin, 7-dehydrocholesterol is converted to vitamin D3 in response to sunlight, a process that is inhibited by sunscreen with a skin protection factor (SPF) of 8 or greater. Once in the blood, vitamin D2 or D3 from diet, or D3 from skin production are carried by an alpha-2-globulin, vitamin D binding protein, and are carried to the liver where they are hydroxylated to yield 25-hydroxyvitamin D (25OHD; calcidiol). 25OHD then is converted in the kidney to 1, 25(OH)2D (calcitriol) by the action of 25OHD-1-alpha hydroxylase (CYP27B1). The CYP27B1 in the kidney is regulated by nearly every hormone involved in calcium homeostasis, and its activity is stimulated by PTH, estrogen, calcitonin, prolactin, growth hormone, low calcium levels, and low phosphorus levels. Its activity is inhibited by calcitriol, thus providing the feedback loop that helps regulates its synthesis.

An excess of vitamin D is unusual, but may lead to hypercalcemia. Vitamin D deficiency may lead to a variety of disorders; the well-described is rickets in growing children or osteomalacia in adults. Evaluating the status of a patient’s vitamin D sufficiency is accomplished by measuring the level of 25-hydroxyvitamin D. Measurement of other metabolites is generally not necessary outside of several unusual metabolic bone disorders or in chronic kidney disease-mineral bone disorder (CKD-MBD).

Indications:

Measurement of vitamin D levels is indicated for patients with:
chronic kidney disease stage III or greater;

osteoporosis;

osteomalacia;

osteopenia;

osteogenesis imperfecta;

osteosclerosis;

hypocalcemia;

hypercalcemia;

hypoparathyroidism;

hyperparathyroidism;

rickets;

vitamin D deficiency to monitor the efficacy of replacement therapy;

fibromyalgia;

granuloma forming diseases;

hypovitaminosis D;

hypervitaminosis D;

long term use of anticonvulsants or glucocorticoids and other medications known to lower -vitamin D levels;

malabsorption states;

obstructive jaundice;

cirrhosis;

psoriasis;

Paget's disease of bone;

gastric bypass.


Limitations:

For Medicare beneficiaries, screening tests are governed by statute (Social Security Act 1861 {nn}). Vitamin D testing may not be used for routine screening.

Assays of calcitriol need not be performed for each of the above conditions. The most common type of vitamin D deficiency is that of 25 OH Vitamin D.

The 1,25-dihydroxy form of vitamin D is generally only required to assist in the diagnosis of certain cases of rare endocrine disorders (primary hyperparathyroidism, hypothyroidism, pseudohypoparathyroidism), or for diagnosing and treating renal osteodystrophy and vitamin D-dependent and vitamin D resistant rickets, or in cases of unknown causes of hypercalcemia, including sarcoidosis. Level of both 25OHD and calcitriol are not needed as a panel for determining a patient's vitamin D status or to monitor routine vitamin D replacement therapy for most diseases. It is expected that the medical record will justify the tests chosen for a particular disease entity, that all available components of 25 OH vitamin D and other metabolite levels will not be performed routinely on every patient and that supportive documentation for test choices will be available to the Contractor upon request.

This Contractor does not expect to receive billing for the various component sources of 25 OH vitamin D separately (such as stored D or diet derived D). Only one total 25 OH vitamin D assay (comprising the sum of both 25OHD2 and 25OHD3) will be considered for reimbursement on any particular day, if medically necessary, for the patient's condition.

Once a beneficiary has been shown to be vitamin D deficient, further testing may be medically necessary only to ensure adequate replacement has been accomplished for this vitamin deficiency, although, generally, other parameters are measured. Annual testing of the vitamin D status may be appropriate depending upon the indication and other mitigating factors. Because there can be variability in individual 25OHD responses to supplemental vitamin D in high-risk individuals, the serum 25OHD levels could be retested after about 3 months of supplementation to confirm that the target 25OHD level has been reached. If the follow up test shows they have not yet reached the target level, the test can it be repeated in another 3 months until the target level is achieved.

Testing Methods
Several methods are available for measuring circulating concentrations of 25-OH-D. Medicare will cover laboratory tests that give practitioners accurate and reliable information. The method used to perform this testing should be validated.

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
999x Not Applicable

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A



ICD-10 Codes that Support Medical Necessity


ICD-10 CODE DESCRIPTION

A15.0 Tuberculosis of lung

A15.4 Tuberculosis of intrathoracic lymph nodes

A15.5 Tuberculosis of larynx, trachea and bronchus

A15.6 Tuberculous pleurisy

A15.7 Primary respiratory tuberculosis

A15.8 Other respiratory tuberculosis

A17.0 Tuberculous meningitis

A17.1 Meningeal tuberculoma

A17.81 Tuberculoma of brain and spinal cord

A17.82 Tuberculous meningoencephalitis

A17.83 Tuberculous neuritis

A17.89 Other tuberculosis of nervous system

A17.9 Tuberculosis of nervous system, unspecified

A18.01 Tuberculosis of spine

A18.02 Tuberculous arthritis of other joints

A18.03 Tuberculosis of other bones

A18.09 Other musculoskeletal tuberculosis

A18.10 Tuberculosis of genitourinary system, unspecified

A18.11 Tuberculosis of kidney and ureter

A18.12 Tuberculosis of bladder

A18.13 Tuberculosis of other urinary organs

A18.14 Tuberculosis of prostate

A18.15 Tuberculosis of other male genital organs

A18.16 Tuberculosis of cervix

A18.17 Tuberculous female pelvic inflammatory disease

A18.18 Tuberculosis of other female genital organs

A18.2 Tuberculous peripheral lymphadenopathy

A18.31 Tuberculous peritonitis

A18.32 Tuberculous enteritis

A18.39 Retroperitoneal tuberculosis

A18.4 Tuberculosis of skin and subcutaneous tissue

A18.50 Tuberculosis of eye, unspecified

A18.51 Tuberculous episcleritis

A18.52 Tuberculous keratitis

A18.53 Tuberculous chorioretinitis

A18.54 Tuberculous iridocyclitis

A18.59 Other tuberculosis of eye

A18.6 Tuberculosis of (inner) (middle) ear

A18.7 Tuberculosis of adrenal glands

A18.81 Tuberculosis of thyroid gland

A18.82 Tuberculosis of other endocrine glands

A18.83 Tuberculosis of digestive tract organs, not elsewhere classified

A18.84 Tuberculosis of heart

A18.85 Tuberculosis of spleen

A18.89 Tuberculosis of other sites

A19.0 Acute miliary tuberculosis of a single specified site

A19.1 Acute miliary tuberculosis of multiple sites

A19.8 Other miliary tuberculosis

C22.0 Liver cell carcinoma

C22.1 Intrahepatic bile duct carcinoma

C22.2 Hepatoblastoma

C22.3 Angiosarcoma of liver

C22.4 Other sarcomas of liver

C22.7 Other specified carcinomas of liver

C22.8 Malignant neoplasm of liver, primary, unspecified as to type

C22.9 Malignant neoplasm of liver, not specified as primary or secondary

C23 Malignant neoplasm of gallbladder

C24.0 Malignant neoplasm of extrahepatic bile duct

C24.1 Malignant neoplasm of ampulla of Vater

C24.8 Malignant neoplasm of overlapping sites of biliary tract

C24.9 Malignant neoplasm of biliary tract, unspecified

C25.0 Malignant neoplasm of head of pancreas

C25.1 Malignant neoplasm of body of pancreas

C25.2 Malignant neoplasm of tail of pancreas

C25.3 Malignant neoplasm of pancreatic duct

C25.4 Malignant neoplasm of endocrine pancreas

C25.7 Malignant neoplasm of other parts of pancreas

C25.8 Malignant neoplasm of overlapping sites of pancreas

C25.9 Malignant neoplasm of pancreas, unspecified

C26.0 Malignant neoplasm of intestinal tract, part unspecified

C26.1 Malignant neoplasm of spleen

C26.9 Malignant neoplasm of ill-defined sites within the digestive system

D13.0 Benign neoplasm of esophagus

D13.1 Benign neoplasm of stomach

D13.2 Benign neoplasm of duodenum

D13.30 Benign neoplasm of unspecified part of small intestine

D13.39 Benign neoplasm of other parts of small intestine

D13.4 Benign neoplasm of liver

D13.5 Benign neoplasm of extrahepatic bile ducts

D13.6 Benign neoplasm of pancreas

D13.7 Benign neoplasm of endocrine pancreas

D13.9 Benign neoplasm of ill-defined sites within the digestive system

D86.0 Sarcoidosis of lung

D86.1 Sarcoidosis of lymph nodes

D86.2 Sarcoidosis of lung with sarcoidosis of lymph nodes

D86.3 Sarcoidosis of skin

D86.81 Sarcoid meningitis

D86.82 Multiple cranial nerve palsies in sarcoidosis

D86.83 Sarcoid iridocyclitis

D86.84 Sarcoid pyelonephritis

D86.85 Sarcoid myocarditis

D86.86 Sarcoid arthropathy

D86.87 Sarcoid myositis

D86.89 Sarcoidosis of other sites

E20.0 Idiopathic hypoparathyroidism

E20.8 Other hypoparathyroidism

E21.0 Primary hyperparathyroidism

E21.1 Secondary hyperparathyroidism, not elsewhere classified

E21.2 Other hyperparathyroidism

E21.4 Other specified disorders of parathyroid gland

CPT 93975, 93976, 93978 - Non invasive abdominal vascular study

Procedure code and Description


Group 1 Codes:

93975 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; COMPLETE STUDY

93976 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF ABDOMINAL, PELVIC, SCROTAL CONTENTS AND/OR RETROPERITONEAL ORGANS; LIMITED STUDY

93978 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR BYPASS GRAFTS; COMPLETE STUDY

93979 DUPLEX SCAN OF AORTA, INFERIOR VENA CAVA, ILIAC VASCULATURE, OR BYPASS GRAFTS; UNILATERAL OR LIMITED STUDY

93980 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE VESSELS; COMPLETE STUDY


93981 DUPLEX SCAN OF ARTERIAL INFLOW AND VENOUS OUTFLOW OF PENILE VESSELS; FOLLOW-UP OR LIMITED STUDY

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity




Overview

Non-invasive abdominal/visceral vascular studies utilize ultrasonic Doppler and physiologic principles to assess the irregularities in blood flow in renal, iliac, and femoral artery systems. These tests are also used to diagnose aortic aneurysms. Noninvasive abdominal/ visceral vascular studies include the patient care required to perform the studies, supervision of the studies, and interpretation of study results, with copies for patient records of test results and analysis of all data, including bi-directional vascular flow or imaging when provided.

Diagnostic tests must be ordered by the physician who is treating the beneficiary and who will use the results in the management of the beneficiary’s specific medical problem. Services are deemed medically necessary when all of the following conditions are met:
Signs/symptoms of ischemia or altered blood flow are present;

The information is necessary for appropriate medical and/or surgical management;

The test is not redundant of other diagnostic procedures that must be performed. Although, in some circumstances, non-invasive vascular tests are complimentary, such as MRA and duplex, where the latter may confirm an indeterminate finding or demonstrate the physiologic significance of an anatomic stenosis such as in renal, iliac, and/or femoral arteries.




Definitions:

Duplex Scans: Duplex combines Doppler and conventional ultrasound, allowing the structure of blood vessels, how the blood is flowing through the vessels, and whether there is any obstruction in the vessels to be seen. Color Doppler produces a picture of the blood vessel, and a computer converts the Doppler sounds into colors overlaid on the image, representing information about the speed and direction of blood flow. Using spectral Doppler analysis, the duplex scan images provide anatomic and hemodynamic information, identifying the presence of any stenosis or plaque in the arteries. Duplex scans are in real-time.

Abdominal/Visceral Vascular Studies 

Abdominal/visceral non-invasive vascular studies are indicated in the evaluation and /or management of vascular disease along with, the narrowing or blockage of arteries that supply blood to the abdomen including intestines (mesenteric vascular disease), pelvic and scrotal contents, and/or retroperitoneal organs including the kidneys (renal vascular disease).
Abdominal, Retroperitoneal and Pelvic Organs (93975, 93976)
Indications:
Uncontrolled hypertension.

Stenosis of visceral artery (atherosclerotic, fibromuscular dysplasia, vasculitis, functional).

Aneurysm of visceral artery.

Portal hypertension, with or without ascites.

Cirrhosis of the liver.

Venous embolism, hemorrhage, infection, and/or thrombosis of visceral vein (renal, hepatic, mesenteric, portal or splenic).

Stenosis of visceral vein (renal, hepatic, mesenteric, portal or splenic).

Complications of internal (biological) (synthetic) prosthetic device implant and/or graft.

Complications in abdominal organ or tissue transplant.

Pain or swelling of scrotal contents which may be a result of suspected obstruction in arterial inflow or venous outflow to testicles or related structure.

Torsion of the spermatic cord; acute epididymitis or epididymoorchitis; or torsion of the testicular appendages.

Hypertension and normotensive renovascular disease with impaired renal function which could be acute kidney failure, chronic kidney disease, end stage renal disease, or other vascular disorders of the kidneys.

Pain or swelling of the female genital organs which may be the result of torsion of the ovaries, ovarian pedicle or fallopian tube.

Trauma to the abdominal, retroperitoneal and/or pelvic organs, arteries, and /or veins.


Aorta, Inferior vena cava, Iliac Vasculature and Bypass grafts (93978, 93979)
Indications:
Atherosclerosis of aorta.

Atherosclerosis of the extremities with intermittent claudication.

Atherosclerosis of other specified arteries.

Aortic aneurysm and dissection.

Aneurysm of iliac artery.

Thromboangiitis obliterans (Buerger’s disease).

Peripheral vascular disease unspecified.

Arterial embolism and thrombosis of abdominal aorta.

Arterial embolism and thrombosis of iliac artery.

Phlebitis and thrombophlebitis of iliac vein.

Venous embolism and thrombosis of vena cava.

Complications related to surgical procedures involving prosthetic device implant, graft, and/or shunts.

Complications of organ or tissue transplant.

Trauma to the chest wall and /or abdomen resulting in a possible injury to the aorta, inferior vena cava and/or iliac vasculature.

Limitations:

Vascular studies are not the initial diagnostic modality for the evaluation of abdominal pain/tenderness. There must be a high index of suspicion that the pain is caused by a vascular disorder, such as mesentery ischemia.

Routine imaging of the iliac veins is not medically necessary. Exceptions will be made for specific medical indications of possible propagation of a known thrombus for consideration for placement of a vena cava filter device via the femoral approach. The medical necessity must be documented in the medical record.

Abdominal aortic aneurysms > four cm in diameter may be followed with abdominal ultrasound every six months. Documentation of medical necessity needs to be provided for studies performed more frequently.

The outcome must impact the clinical management of the patient. For example, if a patient is going to proceed on to other diagnostic and/or therapeutic procedures regardless of the outcome of the noninvasive studies, the non-invasive vascular studies are usually not medically necessary. That is, if it is obvious from the findings of the history and physical examination that the patient is going to proceed to angiography, then noninvasive vascular studies may not be medically necessary.

Penile Vascular Studies (93980, 93981)

Duplex scans of the arterial inflow and venous outflow of penile vessels, have no therapeutic implications. Therefore, they are considered not medically reasonable or necessary, except in a patient with treatment failure who has sustained a documented groin injury where a vascular etiology for impotence is suspected.

Credentialing and Accreditation Standards

The accuracy of non-invasive vascular diagnostic studies depends on the knowledge, skill, and experience of the technologist and interpreter. Consequently, the physician performing and/or interpreting the study must be capable of demonstrating documented training and experience. A vascular diagnostic study may be personally performed by a physician, a certified technologist, or in a certified vascular testing lab.

Services will be considered medically reasonable and necessary only if performed by appropriately trained providers.

All non-invasive vascular diagnostic studies must be performed meeting at least one of the following:
performed by a licensed qualified physician, or

performed by a technician who is certified in vascular technology, or

performed in facilities with laboratories accredited in vascular technology.

A licensed qualified physician for these services is defined as:
Having trained and acquired expertise within the framework of an accredited residency or fellowship program in the applicable specialty/subspecialty in ultrasound (US) or must reflect equivalent education, training, and expertise endorsed by an academic institution in ultrasound or by applicable specialty/subspecialty society in ultrasound, or

Has the Registered Vascular Technologist (RVT), Registered Physician Vascular Interpretation (RPVI), or ASN: Neuroimaging Subspecialty Certification; and

Is able to provide evidence of proficiency in the performance and interpretation of each type of diagnostic procedure performed.

Nonphysician personnel performing tests must demonstrate basic qualifications to perform tests and have training and proficiency as evidenced by licensure or certification by an appropriate State health or education department. In the absence of a State licensing board, non-physician personnel must be certified by an appropriate national credentialing body.

Appropriate personnel certification includes the American Registry of Diagnostic Medical Sonographers (ARDMS), Registered Vascular Technologist (RVT) credential; or Cardiovascular Credentialing International’s Registered Vascular Specialist (RVS).

Laboratories accredited by the Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) Vascular Ultrasound Program, Joint Commission or DNV-GL must follow the accrediting body’s standards.






ICD-10 Codes that Support Medical Necessity



Group 1Codes

ICD-10 CODE DESCRIPTION

I10 Essential (primary) hypertension

I11.0 Hypertensive heart disease with heart failure

I11.9 Hypertensive heart disease without heart failure

I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.0 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.10 Hypertensive heart and chronic kidney disease without heart failure, with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease

I13.11 Hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease

I13.2 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal disease

I15.0 Renovascular hypertension

I15.1 Hypertension secondary to other renal disorders

I15.2 Hypertension secondary to endocrine disorders

I15.8 Other secondary hypertension

I70.1 Atherosclerosis of renal artery


I71.1 Thoracic aortic aneurysm, ruptured

I71.2 Thoracic aortic aneurysm, without rupture

I71.3 Abdominal aortic aneurysm, ruptured

I71.4 Abdominal aortic aneurysm, without rupture

I71.5 Thoracoabdominal aortic aneurysm, ruptured

I71.6 Thoracoabdominal aortic aneurysm, without rupture

I72.2 Aneurysm of renal artery

I72.8 Aneurysm of other specified arteries

I74.01 Saddle embolus of abdominal aorta

I74.09 Other arterial embolism and thrombosis of abdominal aorta

I74.10 Embolism and thrombosis of unspecified parts of aorta

I74.19 Embolism and thrombosis of other parts of aorta

I74.5 Embolism and thrombosis of iliac artery

I74.8 Embolism and thrombosis of other arteries

I75.81 Atheroembolism of kidney

I75.89 Atheroembolism of other site

I76 Septic arterial embolism

I77.2 Rupture of artery

I77.3 Arterial fibromuscular dysplasia

I77.4 Celiac artery compression syndrome

I77.73 Dissection of renal artery

I77.79 Dissection of other specified artery

I77.810 Thoracic aortic ectasia

I77.811 Abdominal aortic ectasia

I77.812 Thoracoabdominal aortic ectasia

I77.819 Aortic ectasia, unspecified site

I80.8 Phlebitis and thrombophlebitis of other sites

I81 Portal vein thrombosis

I82.0 Budd-Chiari syndrome

I82.1 Thrombophlebitis migrans

I82.210 Acute embolism and thrombosis of superior vena cava

I82.211 Chronic embolism and thrombosis of superior vena cava

I82.290 Acute embolism and thrombosis of other thoracic veins

I82.291 Chronic embolism and thrombosis of other thoracic veins

I82.3 Embolism and thrombosis of renal vein

I86.1 Scrotal varices

I86.2 Pelvic varices

I86.3 Vulval varices

I86.4 Gastric varices

I86.8 Varicose veins of other specified sites

K55.011 Focal (segmental) acute (reversible) ischemia of small intestine

K55.012 Diffuse acute (reversible) ischemia of small intestine

K55.019 Acute (reversible) ischemia of small intestine, extent unspecified

K55.021 Focal (segmental) acute infarction of small intestine

K55.022 Diffuse acute infarction of small intestine

K55.029 Acute infarction of small intestine, extent unspecified

K55.031 Focal (segmental) acute (reversible) ischemia of large intestine

K55.032 Diffuse acute (reversible) ischemia of large intestine

K55.039 Acute (reversible) ischemia of large intestine, extent unspecified

K55.041 Focal (segmental) acute infarction of large intestine

K55.042 Diffuse acute infarction of large intestine

K55.049 Acute infarction of large intestine, extent unspecified

K55.051 Focal (segmental) acute (reversible) ischemia of intestine, part unspecified

K55.052 Diffuse acute (reversible) ischemia of intestine, part unspecified

K55.059 Acute (reversible) ischemia of intestine, part and extent unspecified

K55.061 Focal (segmental) acute infarction of intestine, part unspecified

K55.062 Diffuse acute infarction of intestine, part unspecified

K55.069 Acute infarction of intestine, part and extent unspecified

K55.1 Chronic vascular disorders of intestine

K55.30 Necrotizing enterocolitis, unspecified

K55.31 Stage 1 necrotizing enterocolitis

K55.32 Stage 2 necrotizing enterocolitis

K55.33 Stage 3 necrotizing enterocolitis

K55.8 Other vascular disorders of intestine

K70.2 Alcoholic fibrosis and sclerosis of liver

K70.30 Alcoholic cirrhosis of liver without ascites

K70.31 Alcoholic cirrhosis of liver with ascites

K74.0 Hepatic fibrosis

K74.60 Unspecified cirrhosis of liver

K74.69 Other cirrhosis of liver

K76.6 Portal hypertension

N17.0 Acute kidney failure with tubular necrosis

N17.1 Acute kidney failure with acute cortical necrosis

N17.2 Acute kidney failure with medullary necrosis

N17.8 Other acute kidney failure

N17.9 Acute kidney failure, unspecified

N18.1 Chronic kidney disease, stage 1

N18.2 Chronic kidney disease, stage 2 (mild)

N18.3 Chronic kidney disease, stage 3 (moderate)

N18.4 Chronic kidney disease, stage 4 (severe)

N18.5 Chronic kidney disease, stage 5

N26.1 Atrophy of kidney (terminal)

N26.2 Page kidney

N26.9 Renal sclerosis, unspecified

N27.0 Small kidney, unilateral

N27.1 Small kidney, bilateral

CPT CODE 11721, 11055 - Foot care procedure

Procedure codes and Description

Group 1 Codes:

11055 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); SINGLE LESION

11056 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); 2 TO 4 LESIONS

11057 PARING OR CUTTING OF BENIGN HYPERKERATOTIC LESION (EG, CORN OR CALLUS); MORE THAN 4 LESIONS

11719 TRIMMING OF NONDYSTROPHIC NAILS, ANY NUMBER

11720 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 1 TO 5

11721 DEBRIDEMENT OF NAIL(S) BY ANY METHOD(S); 6 OR MORE

G0127 TRIMMING OF DYSTROPHIC NAILS, ANY NUMBER


Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Generally, routine foot care is excluded from coverage. Services that normally are considered routine and not covered by Medicare include the following, regardless of the provider rendering the service:
Cutting or removal of corns and calluses;

Trimming, cutting, clipping, or debridement of nails, including debridement of mycotic nails;

Shaving, paring, cutting or removal of keratoma, tyloma, and heloma;

Other hygienic and preventive maintenance care in the realm of self-care, such as cleaning and soaking the feet, the use of skin creams to maintain skin tone of either ambulatory or bedfast patients;

Any other service performed in the absence of localized illness, injury, or symptoms involving the foot.

Routine foot care is usually performed by the beneficiary himself or herself, or by a caregiver.

However, the Medicare Benefit Policy Manual (Pub. 100-02), Chapter 15, Section 290 describes exceptions to routine foot care exclusions. This LCD outlines such exceptions.


Indications

Routine foot care services are subject to national regulation, which provides definitions, indications and limitations for Medicare payment of routine foot care services.

Exceptions to the routine foot care exclusions include:
Necessary and integral part of otherwise covered services;

Treatment of warts on foot;

Presence of systemic conditions, such as metabolic, neurologic, or peripheral vascular disease;

Mycotic nails:
In the presence of systemic conditions as noted above in #3.

In the absence of systemic conditions:
Ambulatory patient must have marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

Non ambulatory patient suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

Systemic Conditions
Foot care services are covered in the presence of a systemic condition based on the list of illnesses described in Chapter 15, Section 290 of the Benefit Policy Manual.

Diabetes mellitus *
Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities, occlusive peripheral arteriosclerosis)
Buerger’s disease (thromboangiitis obliterans)
Chronic thrombophlebitis *

Peripheral neuropathies involving the feet -
Associated with malnutrition and vitamin deficiency *
Malnutrition (general, pellagra)

Alcoholism

Malabsorption (celiac disease, tropical sprue)

Pernicious anemia

Associated with carcinoma *

Associated with diabetes mellitus *

Associated with drugs and toxins *

Associated with multiple sclerosis *

Associated with uremia (chronic renal disease) *

Associated with traumatic injury

Associated with leprosy or neurosyphilis

Associated with hereditary disorders

Hereditary sensory radicular neuropathy

Angiokeratoma corporis diffusum (Fabry’s)

Amyloid neuropathy

When the patient’s condition is one of those designated by an asterisk (*) above, routine procedures are covered only if the patient is under the active care of a doctor of medicine or osteopathy who documents the condition.

The active care requirement would be considered met if the claim indicates that the patient has seen an M.D. or D.O. for treatment and/or evaluation of the complicating disease process during the 6-month period prior to the service.

Presumption of Coverage

In evaluating whether the routine services can be reimbursed, a presumption of coverage may be made where the evidence available discloses certain physical and/or clinical findings consistent with the diagnosis and indicative of severe peripheral involvement. For purposes of applying this presumption the following findings are pertinent:

Class A Findings

Nontraumatic amputation of foot or integral skeletal portion thereof.

Class B Findings
Absent posterior tibial pulse;

Advanced trophic changes as: hair growth (decrease or absence), nail changes (thickening), pigmentary changes (discoloration), skin texture (thin, shiny), skin color (rubor or redness) (Three required); and

Absent dorsalis pedis pulse.

Class C Findings
Claudication;

Temperature changes (e.g., cold feet);

Edema;

Paresthesias (abnormal spontaneous sensations in the feet); and

Burning.

The presumption of coverage may be applied when the physician rendering the routine foot care has identified:
A Class A finding;

Two of the Class B findings; or

One Class B and two Class C findings.

In addition to a valid billing modifier, these services must include a systemic condition diagnosis listed above and in Group 1 of the diagnosis codes. All claims for routine foot care based on the presence of a systemic condition must have a billing modifier of Q7, Q8 or Q9 to be considered for payment.

Mycotic Nails

Mycotic nail debridement may be a covered service:
In the presence of a systemic disease with the class findings and appropriate Q modifier.

In the absence of systemic disease if the patient has mycotic nails and marked limitation of ambulation, pain, or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

In the absence of systemic disease when a non-ambulatory patient has mycotic nails and suffers from pain or secondary infection resulting from the thickening and dystrophy of infected toenail plate.

For services without systemic disease and class findings, the diagnosis in Group 2 and Group 3 of the diagnosis codes below must be documented in the medical record and submitted on the claim.

The nail debridement procedure codes are considered non-covered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services.

Limitations
Covered exceptions to routine foot care services are considered medically necessary once (1) in 60 days. More frequent services will be denied as not reasonable and necessary.

The exclusion of foot care is determined by the nature of the service, regardless of the clinician who performs the service.

Medicare allows payment for routine foot care only if the conditions under indications are met. These conditions describe the systemic diseases and their peripheral complications that increase the danger for infection and injury if a non-professional provides these services.

Services not meeting the criteria in this statement of national coverage will be denied as statutory non-covered services. For diagnosis codes designated by an asterisk (*), we will require the date the patient was last seen (DPLS) and the NPI of the doctor of medicine or osteopathy actively managing the patients systemic condition.

Nail debridement procedures are considered non-covered routine foot care when these services do not meet the guidelines outlined above for mycotic nail services or are not based on the presence of a systemic condition. If the nail debridement procedures are performed in the absence of mycotic nails and as part of foot care they must meet the same criteria as all other routine foot care services to be considered for payment.

Foot care services that do not require a professional would be considered routine and not a Medicare benefit. Professional in this situation is defined as an M.D., D.O., D.P.M., Nurse Practitioner, Clinical Nurse Specialist, or Physician Assistant.

Loss of protective sensation (LOPS) is not the subject of this LCD. Please refer to NCD 70.2.1.



ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: For codes 11055, 11056, 11057, 11719, 11720, 11721, G0127 billed with modifier Q7, Q8 or Q9. Diagnosis codes with an asterisk also need the date last seen and name and NPI of the attending physician.

For the codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.




Group 1Codes

ICD-10 CODE DESCRIPTION

A30.0 Indeterminate leprosy

A30.1 Tuberculoid leprosy

A30.2 Borderline tuberculoid leprosy

A30.3 Borderline leprosy

A30.4 Borderline lepromatous leprosy

A30.5 Lepromatous leprosy

A30.8 Other forms of leprosy

A30.9 Leprosy, unspecified

A52.10 Symptomatic neurosyphilis, unspecified

A52.11 Tabes dorsalis

A52.12 Other cerebrospinal syphilis

A52.13 Late syphilitic meningitis

A52.14 Late syphilitic encephalitis

A52.15 Late syphilitic neuropathy

A52.16 Charcot's arthropathy (tabetic)

A52.17 General paresis

A52.19 Other symptomatic neurosyphilis

A52.2 Asymptomatic neurosyphilis

A52.3 Neurosyphilis, unspecified

D51.0* Vitamin B12 deficiency anemia due to intrinsic factor deficiency

E08.00 - E13.9* - Opens in a new window Diabetes mellitus due to underlying condition with hyperosmolarity without nonketotic
hyperglycemic-hyperosmolar coma (NKHHC) - Other specified diabetes mellitus without complications

E46* Unspecified protein-calorie malnutrition

E52* Niacin deficiency [pellagra]

E56.9* Vitamin deficiency, unspecified

E64.0* Sequelae of protein-calorie malnutrition

E75.21 Fabry (-Anderson) disease

E75.22 Gaucher disease

E75.240 Niemann-Pick disease type A

E75.241 Niemann-Pick disease type B

E75.242 Niemann-Pick disease type C

E75.243 Niemann-Pick disease type D

E75.248 Other Niemann-Pick disease

E75.249 Niemann-Pick disease, unspecified

E75.3 Sphingolipidosis, unspecified

E77.0 Defects in post-translational modification of lysosomal enzymes

E77.1 Defects in glycoprotein degradation

E77.8 Other disorders of glycoprotein metabolism

E77.9 Disorder of glycoprotein metabolism, unspecified

E85.0 Non-neuropathic heredofamilial amyloidosis

E85.1 Neuropathic heredofamilial amyloidosis


E85.2 Heredofamilial amyloidosis, unspecified

E85.3 Secondary systemic amyloidosis

E85.4 Organ-limited amyloidosis

E85.8 Other amyloidosis

E85.9 Amyloidosis, unspecified
G13.0* Paraneoplastic neuromyopathy and neuropathy


G13.1 Other systemic atrophy primarily affecting central nervous system in neoplastic disease

G35* Multiple sclerosis
G60.0* Hereditary motor and sensory neuropathy

G60.1 Refsum's disease

G60.2* Neuropathy in association with hereditary ataxia

G60.3 Idiopathic progressive neuropathy

G60.8 Other hereditary and idiopathic neuropathies

G60.9 Hereditary and idiopathic neuropathy, unspecified

G61.1 Serum neuropathy

G62.0 Drug-induced polyneuropathy

G62.1* Alcoholic polyneuropathy

G62.2 Polyneuropathy due to other toxic agents

G62.82* Radiation-induced polyneuropathy

G63* Polyneuropathy in diseases classified elsewhere

G65.0 Sequelae of Guillain-Barre syndrome

G65.1 Sequelae of other inflammatory polyneuropathy

G65.2 Sequelae of toxic polyneuropathy

I70.201 Unspecified atherosclerosis of native arteries of extremities, right leg

I70.202 Unspecified atherosclerosis of native arteries of extremities, left leg

I70.203 Unspecified atherosclerosis of native arteries of extremities, bilateral legs

I70.211 Atherosclerosis of native arteries of extremities with intermittent claudication, right leg

I70.212 Atherosclerosis of native arteries of extremities with intermittent claudication, left leg

I70.213 Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs

I70.221 Atherosclerosis of native arteries of extremities with rest pain, right leg

I70.222 Atherosclerosis of native arteries of extremities with rest pain, left leg

I70.223 Atherosclerosis of native arteries of extremities with rest pain, bilateral legs

I70.231 Atherosclerosis of native arteries of right leg with ulceration of thigh

I70.232 Atherosclerosis of native arteries of right leg with ulceration of calf
I70.233 Atherosclerosis of native arteries of right leg with ulceration of ankle

I70.234 Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot


I70.235 Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.238 Atherosclerosis of native arteries of right leg with ulceration of other part of lower right leg

I70.239 Atherosclerosis of native arteries of right leg with ulceration of unspecified site

I70.241 Atherosclerosis of native arteries of left leg with ulceration of thigh

I70.242 Atherosclerosis of native arteries of left leg with ulceration of calf

I70.243 Atherosclerosis of native arteries of left leg with ulceration of ankle

I70.244 Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot

I70.245 Atherosclerosis of native arteries of left leg with ulceration of other part of foot

I70.248 Atherosclerosis of native arteries of left leg with ulceration of other part of lower left leg

I70.249 Atherosclerosis of native arteries of left leg with ulceration of unspecified site

I70.261 Atherosclerosis of native arteries of extremities with gangrene, right leg

I70.262 Atherosclerosis of native arteries of extremities with gangrene, left leg

I70.263 Atherosclerosis of native arteries of extremities with gangrene, bilateral legs
I70.291 Other atherosclerosis of native arteries of extremities, right leg

I70.292 Other atherosclerosis of native arteries of extremities, left leg

I70.293 Other atherosclerosis of native arteries of extremities, bilateral legs

I70.301 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, right leg

I70.302 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, left leg

I70.303 Unspecified atherosclerosis of unspecified type of bypass graft(s) of the extremities, bilateral legs

I70.311 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, right leg

I70.312 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, left leg

I70.313 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudication, bilateral
legs

I70.321 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, right leg


I70.322 Atherosclerosis of unspecified type of bypass graft(s) of the extremities with rest pain, left leg

CPT 80301, g0479, 80300 - Drug testing

Procedure Codes and Description

Group 1 Codes:

G0477 Drug test presump optical

G0478 Drug test presump opt inst

G0479 Drug test presump not opt

G0480 Drug test def 1-7 classes

G0481 Drug test def 8-14 classes

G0482 Drug test def 15-21 classes

G0483 Drug test def 22+ classes

Group 2 Paragraph: The following CPT codes are Non-Covered by Medicare

Group 2 Codes:

80300 Drug screen non tlc devices

80301 Drug screen class list a

80302 Drug screen prsmptv 1 class

80303 Drug screen one/mult class

80304 Drug screen one/mult class

80320 - 80377 Drug screen quantalcohols - Drug/substance nos 7/more

Coverage Indications, Limitations, and/or Medical Necessity

A qualitative/presumptive drug screen is used to detect the presence of a drug in the body. A blood or urine sample may be used. However, urine is the best specimen for broad screening, as blood is relatively insensitive for many common drugs, including psychotropic agents, opioids, and stimulants.
Common methods of drug analysis include chromatography, immunoassay, chemical ("spot") tests, and spectrometry.

Analysis is comparative, matching the properties or behavior of a substance with that of a valid reference compound (a laboratory must possess a valid reference agent for every substance that it identifies). Drugs or classes of drugs are commonly assayed by qualitative/presumptive testing. A test may be followed by confirmation with a second method, only if there is a positive or negative inconsistent finding from the qualitative/presumptive test in the setting of a symptomatic patient, as described below.

Examples of drugs or classes of drugs that are commonly assayed by qualitative/presumptive tests, followed by confirmation with a second method, are: alcohols, amphetamines, barbiturates/sedatives, benzodiazepines, cocaine and metabolites, methadone, antihistamines, stimulants, opioid analgesics, salicylates, cardiovascular drugs, antipsychotics, cyclic antidepressants, and others. Focused drug screens, most commonly for illicit drug use, may be more useful clinically.

Indications:

A. Although technology has provided the ability to measure many toxins, most toxicological diagnoses and therapeutic decisions are made based on historical or clinical considerations:
Laboratory turnaround time can often be longer than the critical intervention time course of an overdose.

The cost and support of maintaining the instruments, staff training, and specialized labor involved in some analyses are prohibitive.

For many toxins there are no established cutoff levels of .toxicity, making interpretation of the results difficult.

Although comprehensive screening is unlikely to affect emergency management, the results may assist the admitting physicians in evaluating the patient if the diagnosis remains unclear. Screening panels should be used when the results will alter patient management or disposition.

B. A qualitative/presumptive drug test may be indicated for a variety of reasons including the following:
1. A symptomatic patient when the history is unreliable, when there has been a suspected multiple-drug ingestion, to determine the cause of delirium or coma, or for the identification of specific drugs that may indicate when antagonists may be used.
2. For monitoring patient compliance during active treatment for substance abuse or dependence.
3. To monitor for compliance/adherence to the treatment plan or illicit drug use in patients under treatment or seeking treatment for a chronic pain condition. The clinical utility of drug tests in the emergency setting may be limited because patient management decisions are unaffected, since most therapy for drug poisonings is symptom directed and supportive.

C. Medicare will consider performance of a qualitative/presumptive drug test reasonable and necessary when a patient presents with suspected drug overdose and one or more of the following conditions:
Unexplained coma

Unexplained altered mental status in the absence of a clinically defined toxic syndrome or toxidrome

Severe or unexplained cardiovascular instability (cardiotoxicity)

Unexplained metabolic or respiratory acidosis in the absence of a clinically defined toxic syndrome or toxidrome

Testing on neonates suspected of prenatal drug exposure

Seizures with an undetermined history

D. Medicare will consider performance of a qualitative/presumptive drug test reasonable and necessary when a patient presents with one or more of the following conditions:
For monitoring patient compliance during active treatment for substance abuse or dependence.

A drug screen is considered medically reasonable and necessary in patients on chronic opioid therapy:
- In whom illicit drug use, non-compliance or a significant pre-test probability of non-adherence to the prescribed drug regimen is suspected and documented in the medical record; and/or
- In those who are at high risk for medication abuse due to psychiatric issues, who have engaged in aberrant drug-related behaviors, or who have a history of substance abuse.

Medicare will consider performance of a drug test reasonable and necessary in patients with chronic pain to:
- determine the presence of other substances prior to initiating pharmacologic treatment
- detect the presence of illicit drugs
- monitor adherence to the plan of care

Drugs, or drug classes for which testing is performed, should reflect only those likely to be present, based on the patient's medical history, current clinical presentation, and illicit drugs that are in common use. Drugs for which specimens are being tested must be indicated by the referring provider in a written order.

A drug test may be reasonable and necessary for patients with known substance abuse or dependence, only when the clinical presentation has changed unexpectedly and one of the above indications is met.

A drug test may be reasonable and necessary for patients with symptoms of schizophrenia suspected to be secondary to drug or substance intoxication.

Definitive drug testing is indicated when:
1. The results of the screen are presumptively positive.
2. Results of the screen are negative and this negative finding is inconsistent with the patient's medical history.
3. This test may also be used, when the coverage criteria of the policy are met AND there is no presumptive test available, locally and/or commercially, as may be the case for certain synthetic or semi-synthetic opioids.

A positive screen often results in an inadequate result upon which to make a proper determination. A more specific method, such as gas or liquid chromatography coupled with mass spectrometry, may be needed in order to obtain a confirmed analytical result. In particular, screens are frequently inadequate for interpretation of opiate and benzodiazepine results and therefore; quantitative testing may be needed in these instances. Confirmation testing is usually not required for drugs like methadone, wherein false positive results are rare. However, factors such as cross-reactivity with other similar compounds or interfering substances in the specimen may affect test results. Confirmatory testing eliminates the risk of false positives. Also, eliminated by confirmation, is the risk of a “pill scraper” slipping through. Patients diverting their drug, attempt to cheat the test by scraping a bit of drug from a pill into their urine sample. It would screen positive, but there would be no metabolite upon confirmation. Frequent use of this code will be monitored for appropriateness.

Limitations:

It is considered not reasonable or necessary to test for the same drug with both a blood and a urine specimen simultaneously.

Drug screening for medico-legal purposes (e.g., court-ordered drug screening) or for employment purposes (e.g., as a pre-requisite for employment or as a requirement for continuation of employment) are not covered.


Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
N/A

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the policy, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

ICD-10 Codes that Support Medical Necessity

Group 1 Paragraph: For monitoring of patient compliance in a drug treatment program, use diagnosis code Z03.89 as the primary diagnosis and the specific drug dependence diagnosis as the secondary diagnosis.

For the monitoring of patients on methadone maintenance and chronic pain patients with opioid dependence use diagnosis code Z79.891, suspected of abusing other illicit drugs, use diagnosis code Z79.899.

G0477, G0478, G0479, G0480, G0481, G0482, G0483

Diagnosis codes must be coded to the highest level of specificity.

For codes in the table below that require a 7th character, letter A initial encounter, D subsequent encounter or S sequela may be used.

ICD-10 CODE DESCRIPTION

E87.2 Acidosis

F11.20 Opioid dependence, uncomplicated

F18.10 Inhalant abuse, uncomplicated

F18.120 Inhalant abuse with intoxication, uncomplicated

F18.90 Inhalant use, unspecified, uncomplicated

F19.20 Other psychoactive substance dependence, uncomplicated

F20.0 Paranoid schizophrenia

F20.1 Disorganized schizophrenia

F20.2 Catatonic schizophrenia

F20.89 Other schizophrenia

F55.3 Abuse of steroids or hormones

F55.8 Abuse of other non-psychoactive substances

I45.81 Long QT syndrome

I47.2 Ventricular tachycardia

R40.0 Somnolence

R40.1 Stupor

R40.20 Unspecified coma

R40.2110 Coma scale, eyes open, never, unspecified time

R40.2111 Coma scale, eyes open, never, in the field [EMT or ambulance]

R40.2112 Coma scale, eyes open, never, at arrival to emergency department

R40.2113 Coma scale, eyes open, never, at hospital admission

R40.2114 Coma scale, eyes open, never, 24 hours or more after hospital admission

R40.2120 Coma scale, eyes open, to pain, unspecified time

R40.2121 Coma scale, eyes open, to pain, in the field [EMT or ambulance]

R40.2122 Coma scale, eyes open, to pain, at arrival to emergency department

R40.2123 Coma scale, eyes open, to pain, at hospital admission

R40.2124 Coma scale, eyes open, to pain, 24 hours or more after hospital admission

R40.2210 Coma scale, best verbal response, none, unspecified time

R40.2211 Coma scale, best verbal response, none, in the field [EMT or ambulance]

R40.2212 Coma scale, best verbal response, none, at arrival to emergency department

R40.2213 Coma scale, best verbal response, none, at hospital admission

R40.2214 Coma scale, best verbal response, none, 24 hours or more after hospital admission

R40.2220 Coma scale, best verbal response, incomprehensible words, unspecified time

R40.2221 Coma scale, best verbal response, incomprehensible words, in the field [EMT or ambulance]

R40.2222 Coma scale, best verbal response, incomprehensible words, at arrival to emergency department

R40.2223 Coma scale, best verbal response, incomprehensible words, at hospital admission

R40.2224 Coma scale, best verbal response, incomprehensible words, 24 hours or more after hospital admission

R40.2310 Coma scale, best motor response, none, unspecified time

R40.2311 Coma scale, best motor response, none, in the field [EMT or ambulance]

R40.2312 Coma scale, best motor response, none, at arrival to emergency department

R40.2313 Coma scale, best motor response, none, at hospital admission

R40.2314 Coma scale, best motor response, none, 24 hours or more after hospital admission

R40.2320 Coma scale, best motor response, extension, unspecified time

R40.2321 Coma scale, best motor response, extension, in the field [EMT or ambulance]

R40.2322 Coma scale, best motor response, extension, at arrival to emergency department

R40.2323 Coma scale, best motor response, extension, at hospital admission

R40.2324 Coma scale, best motor response, extension, 24 hours or more after hospital admission

R40.2340 Coma scale, best motor response, flexion withdrawal, unspecified time

R40.2341 Coma scale, best motor response, flexion withdrawal, in the field [EMT or ambulance]

R40.2342 Coma scale, best motor response, flexion withdrawal, at arrival to emergency department

R40.2343 Coma scale, best motor response, flexion withdrawal, at hospital admission

R40.2344 Coma scale, best motor response, flexion withdrawal, 24 hours or more after hospital admission

R41.0 Disorientation, unspecified

R41.82 Altered mental status, unspecified

R44.0 Auditory hallucinations

R44.2 Other hallucinations

R56.9 Unspecified convulsions

T39.011A Poisoning by aspirin, accidental (unintentional), initial encounter

T39.012A Poisoning by aspirin, intentional self-harm, initial encounter

T39.013A Poisoning by aspirin, assault, initial encounter

T39.014A Poisoning by aspirin, undetermined, initial encounter

T39.091A Poisoning by salicylates, accidental (unintentional), initial encounter

T39.092A Poisoning by salicylates, intentional self-harm, initial encounter

T39.093A Poisoning by salicylates, assault, initial encounter

T39.094A Poisoning by salicylates, undetermined, initial encounter

T39.1X1A Poisoning by 4-Aminophenol derivatives, accidental (unintentional), initial encounter

T39.1X2A Poisoning by 4-Aminophenol derivatives, intentional self-harm, initial encounter

T39.1X3A Poisoning by 4-Aminophenol derivatives, assault, initial encounter

T39.1X4A Poisoning by 4-Aminophenol derivatives, undetermined, initial encounter

T39.2X1A Poisoning by pyrazolone derivatives, accidental (unintentional), initial encounter

T39.2X2A Poisoning by pyrazolone derivatives, intentional self-harm, initial encounter

T39.2X3A Poisoning by pyrazolone derivatives, assault, initial encounter

T39.2X4A Poisoning by pyrazolone derivatives, undetermined, initial encounter

T39.311A Poisoning by propionic acid derivatives, accidental (unintentional), initial encounter

T39.312A Poisoning by propionic acid derivatives, intentional self-harm, initial encounter

T39.313A Poisoning by propionic acid derivatives, assault, initial encounter

T39.314A Poisoning by propionic acid derivatives, undetermined, initial encounter

T39.391A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], accidental (unintentional), initial
encounter

T39.392A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], intentional self-harm, initial encounter

T39.393A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], assault, initial encounter

T39.394A Poisoning by other nonsteroidal anti-inflammatory drugs [NSAID], undetermined, initial encounter

T40.0X1A Poisoning by opium, accidental (unintentional), initial encounter

T40.0X2A Poisoning by opium, intentional self-harm, initial encounter

T40.0X3A Poisoning by opium, assault, initial encounter

T40.0X4A Poisoning by opium, undetermined, initial encounter

T40.1X1A Poisoning by heroin, accidental (unintentional), initial encounter

T40.1X2A Poisoning by heroin, intentional self-harm, initial encounter

T40.1X3A Poisoning by heroin, assault, initial encounter

T40.1X4A Poisoning by heroin, undetermined, initial encounter

T40.2X1A Poisoning by other opioids, accidental (unintentional), initial encounter

T40.2X2A Poisoning by other opioids, intentional self-harm, initial encounter

T40.2X3A Poisoning by other opioids, assault, initial encounter

T40.2X4A Poisoning by other opioids, undetermined, initial encounter

T40.3X1A Poisoning by methadone, accidental (unintentional), initial encounter

T40.3X2A Poisoning by methadone, intentional self-harm, initial encounter

T40.3X3A Poisoning by methadone, assault, initial encounter

T40.3X4A Poisoning by methadone, undetermined, initial encounter

T40.4X1A Poisoning by other synthetic narcotics, accidental (unintentional), initial encounter

T40.4X2A Poisoning by other synthetic narcotics, intentional self-harm, initial encounter

T40.4X3A Poisoning by other synthetic narcotics, assault, initial encounter



Cosmetic surgery CPT code list - 19318, 15830, 19380

Procedure Codes and Description

Group 1 Paragraph: N/A

Group 1 Codes:

11920 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.0 SQ CM OR LESS

11921 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; 6.1 TO 20.0 SQ CM

11922 TATTOOING, INTRADERMAL INTRODUCTION OF INSOLUBLE OPAQUE PIGMENTS TO CORRECT COLOR DEFECTS OF SKIN, INCLUDING MICROPIGMENTATION; EACH ADDITIONAL 20.0 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
15775 - 15776 PUNCH GRAFT FOR HAIR TRANSPLANT; 1 TO 15 PUNCH GRAFTS - PUNCH GRAFT FOR HAIR TRANSPLANT; MORE THAN 15 PUNCH GRAFTS

15781 DERMABRASION; SEGMENTAL, FACE

15788 - 15793 CHEMICAL PEEL, FACIAL; EPIDERMAL - CHEMICAL PEEL, NONFACIAL; DERMAL

15828 RHYTIDECTOMY; CHEEK, CHIN, AND NECK

15829 RHYTIDECTOMY; SUPERFICIAL MUSCULOAPONEUROTIC SYSTEM (SMAS) FLAP

15830 EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN, INFRAUMBILICAL PANNICULECTOMY

19300 MASTECTOMY FOR GYNECOMASTIA

19316 MASTOPEXY

19318 REDUCTION MAMMAPLASTY

19324 MAMMAPLASTY, AUGMENTATION; WITHOUT PROSTHETIC IMPLANT

19325 MAMMAPLASTY, AUGMENTATION; WITH PROSTHETIC IMPLANT

19328 REMOVAL OF INTACT MAMMARY IMPLANT

19330 REMOVAL OF MAMMARY IMPLANT MATERIAL

19340 IMMEDIATE INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION

19342 DELAYED INSERTION OF BREAST PROSTHESIS FOLLOWING MASTOPEXY, MASTECTOMY OR IN RECONSTRUCTION

19350 NIPPLE/AREOLA RECONSTRUCTION

19355 CORRECTION OF INVERTED NIPPLES

19357 BREAST RECONSTRUCTION, IMMEDIATE OR DELAYED, WITH TISSUE EXPANDER, INCLUDING SUBSEQUENT EXPANSION

19361 BREAST RECONSTRUCTION WITH LATISSIMUS DORSI FLAP, WITHOUT PROSTHETIC IMPLANT

19364 BREAST RECONSTRUCTION WITH FREE FLAP

19366 BREAST RECONSTRUCTION WITH OTHER TECHNIQUE

19367 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF
DONOR SITE;

19368 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), SINGLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE; WITH MICROVASCULAR ANASTOMOSIS (SUPERCHARGING)

19369 BREAST RECONSTRUCTION WITH TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP (TRAM), DOUBLE PEDICLE, INCLUDING CLOSURE OF DONOR SITE

19370 OPEN PERIPROSTHETIC CAPSULOTOMY, BREAST

19371 PERIPROSTHETIC CAPSULECTOMY, BREAST

19380 REVISION OF RECONSTRUCTED BREAST

19396 PREPARATION OF MOULAGE FOR CUSTOM BREAST IMPLANT

30400 - 30450 RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP - RHINOPLASTY, SECONDARY; MAJOR REVISION (NASAL TIP WORK AND OSTEOTOMIES)

C9800 DERMAL INJECTION PROCEDURE(S) FOR FACIAL LIPODYSTROPHY SYNDROME (LDS) AND PROVISION OF RADIESSE OR SCULPTRA DERMAL FILLER, INCLUDING ALL ITEMS AND SUPPLIES

G0429 DERMAL FILLER INJECTION(S) FOR THE TREATMENT OF FACIAL LIPODYSTROPHY SYNDROME (LDS) (E.G., AS A RESULT OF HIGHLY ACTIVE ANTIRETROVIRAL THERAPY)

Q2026 INJECTION, RADIESSE, 0.1 ML

Q2028 INJECTION, SCULPTRA, 0.5 MG


Coverage Indications, Limitations, and/or Medical Necessity

According to the American Society of Plastic and Reconstructive Surgeons, the specialty of plastic surgery includes reconstructive and cosmetic procedures:

Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, involutional defects, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.

Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.

Indications for specific surgical procedures:

Breast reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is covered.

Removal or revision of a breast implant is considered medically necessary when it is removed for one of the following reasons:

Mechanical complication of breast prosthesis; including rupture or failed implant, and/or implant extrusion

Infection or inflammatory reaction due to a breast prosthesis; including infected breast implant, or rejection of breast implants.

Other complication of internal breast implant; including siliconoma, granuloma, interference with diagnosis of breast cancer, and/or painful capsular contracture with disfigurement.

Reduction Mammoplasty is the surgical reshaping of the breasts to reduce or lift enlarged or sagging breasts. Cosmetic surgery to reshape the breasts to improve appearance is not a Medicare benefit.

Macromastia (breast hypertrophy) is an increase in the volume and weight of breast tissue relative to the general body habitus. Breast hypertrophy may adversely affect other body systems: musculoskeletal, respiratory, and integumentary. Unilateral hypertrophy may result in symptoms following contralateral mastectomy.

Medical necessity for a reduction mammoplasty is limited to circumstances in which:

There are signs and/or symptoms resulting from the enlarged breasts (macromastia) that have not responded adequately to non-surgical interventions, and To reduce the size of a normal breast to bring it into symmetry with a breast reconstructed after cancer surgery.

Non-surgical interventions preceding reduction mammoplasty should include as appropriate, but are not limited to, the following:

Determining the macromastia is not due to an active endocrine or metabolic process.

Determining the symptoms are refractory to appropriately fitted supporting garments, or following unilateral mastectomy, persistent with an appropriately fitted prosthesis or reconstruction therapy at the site of the absent breast.

Determining that dermatologic signs and/or symptoms are refractory to, or recurrent following, a completed course of medical management.

A medically reasonable and necessary reduction mammoplasty could be indicated in the presence of significantly enlarged breasts and the presence of at least one of the following signs and/or symptoms:

Back, neck or shoulder pain from macromastia and unrelieved by 6 months of:

Conservative analgesia,

Supportive measures (garment, etc.),

Physical Therapy, or

Significant arthritic changes in the cervical or upper thoracic spine, optimally managed with persistent symptoms and/or significant restriction of activity, or

Intertriginous maceration or infection of the inframammary skin refractory related to dermatologic measures.

Permanent shoulder grooving with skin irritation by supporting garment (bra strap).

The amount of breast tissue to be removed must be proportional to the body surface area (BSA) per the Schnur scale below. If only one breast meets the Schnur scale criteria; breast tissue may be removed from the other breast in order to achieve symmetry.

Schnur Scale:

Body Surface

Area (m2) Average grams of tissue per breast to be removed

1.40-1.50 218-260

1.51–1.60 261-310

1.61-1.70 311-370

1.71-1.80 371-441

1.81-1.90 442-527

1.91-2.00 528-628

2.01-2.10 629-750

2.11-2.20 751-895

2.21-2.30 896-1068

2.31-2.40 1069-1275

2.41-2.50 1276-1522

2.51-2.60 1523-1806

2.61-2.70 1807-2154

2.71-2.80 2155-2568

2.81-2.90 2569-3061

2.91-3.00 3062-3650


Mastectomy for gynecomastia 

Gynecomastia is the excessive growth of the male mammary glands. These conditions can cause significant clinical manifestations when the excessive breast weight adversely affects the supporting structures of the shoulders, neck, and trunk. Payment may be made for this procedure if it is documented that the tissue is primarily breast tissue and not just adipose (fatty tissue).

Tattooing to correct color defects of the skin may be considered reconstructive when performed in connection with a payable post-mastectomy reconstruction, or for reconstruction following trauma or removal of cancer from an eyelid, eyebrow or lip(s).

Punch graft hair transplant may be considered reconstructive when it is performed for eyebrow(s) replacement following a burn injury or tumor removal.

Rhinoplasty that is performed to improve nasal respiratory function due to airway obstruction or stricture, repair deficits caused by trauma, revise structural deformities produced by trauma or nasal cutaneous disease, or replace nasal tissue lost after tumor ablative surgery is covered.


Nasal fracture

Benign or malignant neoplasms

Nasal Obstruction

Chemical Peel

Is covered for the treatment of Actinic Keratosis.

Dermabrasion, segmental, face is covered for the treatment of rhinophyma.

Dermal injections for facial LDS using dermal fillers approved by the FDA for this purpose, and then only in HIV-infected Medicare beneficiaries who manifest depression secondary to the physical stigma of HIV treatment will be covered. Effective for claims with dates of service on and after March 23, 2010.

See Pub. 100-03, Medicare National Coverage Determinations Chapter 1, Coverage Determinations Part 4, Section 250.5, for specific coverage criteria. See Pub. 100-04, Claims Processing Manual, Chapter 32, Section 260, for specific claims payment/coding instructions.

The following procedures will be considered on an individual basis.
Rhytidectomy is considered medically necessary to correct a functional impairment as a result of a disease state ie; facial paralysis. Often this procedure is performed in conjunction with other procedures to correct the impairment.

Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) will only be considered reasonable and medically necessary when these procedures are performed due to another surgery being done at the same time and would effect the healing of the surgical incision.

This procedure may also be considered to be medically necessary for the patient that has had a significant weight-loss following the treatment of morbid obesity and there are medical complications such as candidiasis, intertrigo or tissue necrosis that is unresponsive to oral or topical medication.

These claims will be reviewed by the medical staff and considered on a case by case basis. Medical Records will be requested by the Contractor to determine medical necessity. See Documentation Requirements section of this LCD.

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