Medicare Medical Necessity - LabCorp JL .pdfZ46.1 Encounter for fitting and adjustment of hearing...

Medicare Medical NecessityDocumenting Medicare Medical Necessity of Laboratory Services

Novitas Solutions, Inc.Medicare Administrative Contractor

Jurisdiction LDecember 2019 Edition

This document is provided as an informational service to LabCorp accounts. The document contains certain Local Coverage Determinations issued at various times by the Medicare Administrative Contractor (MAC) and National Coverage Determinations issued by the Centers for Medicare and Medicaid Services. The information compiled herein is as of December 9, 2019. There can be no representation or warranty as to the accuracy or completeness of the information or that use of this information will comply with the local or national policies. To ensure the accurate and appropriate use of the information, it is recommended that the MAC be consulted. Primary sources (i.e. MAC publications, notices, and advice) should be consulted prior to the use of this information for purposes other than for submitting diagnosis codes to LabCorp. This is particularly important since information is often affected by ongoing developments.

Medicare Medical Necessity

The Centers for Medicare and Medicaid Services (CMS) requires MACs to establish policies to ensure the medical necessity of services being paid for by the Medicare program. CMS itself established national policies and effective November 25, 2002, implemented the National Coverage Determinations (NCDs). MACs will approve payment only for those particular test procedures when they have determined them to be medically necessary for the patient. As a result, a claim submitted for payment of a test on a local or national list without a specific diagnosis code (ICD-10-CM) that indicates medical necessity based upon the local or national policies will result in denial of payment for these services. This policy applies to all Medicare Part B providers of clinical laboratory services.

CMS in conjunction with the Public Health Service presented guidelines for diagnosis coding. In part these guidelines state:

ICD-10-CM are to be used at their highest level of specificity, e.g.,− Assign 3-digit codes only if there are no 4, 5, or 6-character codes within that code subcategory,− Assign 4, 5, and 6-character subcategory codes only if there is no 7-character extension code for that category− Assign 7-character extension code for those categories where it exists.− Assign a “X” placeholder code(s) if a 7-character extension code is needed and there are no 4, 5, or 6 characters within that subcategory.

ICD-10-CM is composed of codes with either 3-7 characters. Codes with 3 characters are included in ICD-10-CM as standalone codes or as the heading of a category of codes that are further subdivided by the use of fourth, fifth, and sixth characters and a seventh character extension which provide greater specificity. The first character of a three-character category is always a letter (A-Z excluding U); the second and third characters may be numbers or alpha characters; and the fourth through seventh characters can be any combination of letters (excluding U) and numbers. In instances when a letter or number is not an option for the fourth, fifth, or sixth characters, the letter “X” is used as a placeholder to allow future expansion without disturbing the coding structure.

The MAC, Novitas Solutions, Inc., has established specific prepayment medical necessity documentation requirements for certain laboratory tests. These local tests plus the national ones are listed on the following pages. If you have any questions regarding the policies listed in this document, please contact the Novitas Solutions, Inc. Medicare Part B office at 877-235-8073.

Novitas Solutions, Inc. will not pay for the listed tests unless the claim is accompanied by an appropriate diagnostic code. For your convenience, we have developed this document from information published by Novitas Solutions, Inc. or CMS to provide you with a list of medically acceptable diagnostic codes for each of these tests.

So that we can properly bill the appropriate party or MAC, we ask that you include an ICD-10-CM diagnosis code on the test request form when ordering each of these tests for beneficiaries. We do ask that you include the specific ICD-10-CM code(s) rather than a descriptive diagnosis on each patient. It is critical that the diagnosis codes that you provide are consistent with those documented in the patient’s record.

Novitas Solutions, Inc. – Delaware, District of Columbia, Maryland, New Jersey & PennsylvaniaMedical Necessity Policies as of December 9, 2019

Laboratory Test CPT• *ICD-10-CM Codes Always Denied • Services that are not Reasonable and Necessary 0111T , 83719• Allergy Testing 82785, 86001, %86003, 86005, %86008• *Alpha-Fetoprotein 82105• Assays for Vitamins and Metabolic Function %82180, %82306, %82379, %82607, %82652, %82746, %83090, %83698, %84207, %84252, 84255, %84425, %84446, %84590, 84591, %84597, 84999, %85385, 86352• Biomarkers for Oncology 81120, 81121, 81170, 81175, 81176,

81206, 81207, 81208, 81210, 81218, 81219, 81233, 81235, 81236,81237, 81245, 81246, 81261, 81262, 81263, 81270, 81272, 81273, 81275,81276, 81287, 81292-81294,81301, 81305, 81310, 81311, 81313-81316, 81320- 81323, 81327, 81334, 81340, 81342, 81345, 81350, 81400-81408, 81435- 81438, 81445, 81450, 81479, 81503, 81520, 81525, 81538, 81540, 81545, 0003U, 0022U

• Biomarkers Overview 81161, 81200-81205, 81209, 81220- 81229, 81240-81244, 81250-81260, 81265-81269, 81288, 81290-81304, 81329, 81317-81332, 81336, 81337, 81355, 81370-81383, 81410-81431, 81434, 81439, 81440, 81442, 81460- 81471, 81490, 81595• *Blood Counts 85004, 85007, 85008, 85013-85032,

85048, 85049• *Blood Glucose Testing %82947, %82948, %82962• BRCA1 and BRCA2 Genetic Testing %81162-%81167, %81212, %81215, %81216, %81217, %81432, %81433, %81445, %81455• *Carcinoembryonic Antigen (CEA) %82378• *Cardiovascular Disease Screening %80061, %82465, %83718, %84478• *Collagen Cross Links, Any Method %82523• *Colorectal Cancer Screening %82270, %G0328• Controlled Substance Monitoring and Drugs of Abuse Testing %80305-%80307, %G0480-%G0483, %G0659• C-Reactive Protein High Sensitivity Testing (hsCRP) %86141• *Cytogenetic Studies %88230-%88299• *Diabetes Screening Tests %82947, %82950, %82951• *Digoxin Therapeutic Assay %80162• *Fecal Occult Blood %82272• Flow Cytometry %88182-%88189• *Gamma Glutamyl Transferase (GGT) %82977• *Glycated Hemoglobin/*Glycated Protein %83036, %82985• *Hepatitis Panel/Acute Hepatitis Panel 80074• *Histocompatibility Testing 86812, 86813, 86816, 86817, 86821,

86825, 86826• *Human Chorionic Gonadotropin (hCg) %84702• *Human Immunodeficiency Virus (HIV) Infection, Screening %G0432, %G0433, %G0435, %G0475• *Human Immunodeficiency Virus (HIV) Testing (Diagnosis) %86689, %86701-%86703, %87390,

%87391, %87534, %87535, %87537 %87538

• *Human Immunodeficiency Virus (HIV) Testing (Prognosis Including 87536, 87539 Monitoring)• In Vitro Chemosensitivity & Chemoresistance Assays 81535, 81536, 84999, 89240

Laboratory Test CPT • *Lipid Testing %80061, %82465, 83700, 83701,

83704, %83718, %83721, %84478• Loss-of-Heterozygosity Based Topographic Genotyping with %81479 Pathfinder TG®• *Lymphocyte Mitogen Response Assays 86353• Molecular Diagnostics: Genitourinary Infectious Disease Testing 87480, %87481, 87490, 87491, 87510,

87590, 87591, 87660, %87798• *Pap Smears, Diagnostic 88141-88175• *Pap Smears, Screening %G0123, %G0124, %G0141, %G0143,

%G0144, %G0145, %G0147, %G0148, %P3000, %P3001

• *Partial Thromboplastin Time (PTT) 85730• *Prostate Cancer Screening Test %G0103• *Prostate Specific Antigen %84153• *Prothrombin Time %85610• *Screening for Cervical Cancer with Human Papillomavirus (HPV) %G0476 Testing• *Screening for Hepatitis B Virus (HBV) Infection %G0499, %86704, %86706, %87340,

%87341• *Screening for Hepatitis C Virus (HCV) in Adults %G0472• *Screening for Sexually Transmitted Infections (STIs) %86592, %86593, %86631, %86632,

%86780, %87110, %87270, %87320, %87340, %87341, %87490, %87491, %87590, %87591, %87800, %87810, %87850

• *Serum Iron Studies %82728, 83540, 83550, 84466• *Sweat Test 82438, 89230• *Thyroid Testing %84436, %84439, %84443, %84479• *Tumor Antigen by Immunoassay CA15-3/CA 27.29 86300• *Tumor Antigen by Immunoassay CA 19-9 86301• *Tumor Antigen by Immunoassay CA125 %86304• *Urine Bacterial Culture 87086, 87088

* Indicates national policy %Indicates Frequency

CPT copyright American Medical Association

Novitas Solutions, Inc. – Delaware, District of Columbia, Maryland, New Jersey & PennsylvaniaMedical Necessity Policies as of December 9, 2019

Determining Necessity of Advance Beneficiary Notice (ABN) Completion*

Diagnose. Determine your patient’s diagnosis.1. Document. Write the diagnosis code(s) on the front of the requisition.2. Verify. Determine if the laboratory test(s) ordered for the patient is subject to Local Coverage Determination or National Coverage Determination. This information can be located in the policies published by the MAC, CMS, or www.LabCorp.com/MedicareMedicalNecessity.com 3. Review. If the diagnosis code for your patient does not meet the medical necessity requirements set forth by Medicare or the test(s) is being performed more frequently than Medicare allows, an ABN should be completed.

*An ABN should be completed for all tests that are considered investigational (experimental or for research use) by Medicare.

Payment Denials and Advance Beneficiary Notices

The Medicare program will allow the laboratory to bill the patient for denied limited coverage services only if an Advance Beneficiary Notice (ABN) is completed, signed and dated by the patient, and forwarded to the laboratory prior to testing. Please provide the signed ABN with the original order. It is the physician’s responsibility to ensure that the beneficiary receives and signs an ABN to accept financial responsibility if Medicare does not pay for these services.

ABNs may be obtained from your LabCorp representative.

Policy UpdatesLabCorp will continue to provide you with information regarding specific coverage limitation policies of the MAC and CMS, in the event that new policies are issued or existing ones are changed or clarified.

Although all health care providers are being affected by these types of policies, we are very sensitive to the challenges these changes bring to you and your patients. Please be assured that we will continue to work to lessen the impact upon you and your patients.

Contact your local billing representative if you have questions regarding this information.

Centers for Medicare and Medicaid Services — All States

Non-Covered ICD-10-CM Codes for All Lab NCDsN/A

Alpha SortZ62.21 Child in welfare custodyZ56.4 Discord with boss and workmatesZ59.2 Discord with neighbors, lodgers and landlordZ02.9 Encounter for administrative examinations, unspecifiedZ02.82 Encounter for adoption servicesZ36.86 Encounter for antenatal screening for cervical lengthZ36.0 Encounter for antenatal screening for chromosomal anomaliesZ36.4 Encounter for antenatal screening for fetal growth retardationZ36.84 Encounter for antenatal screening for fetal lung maturityZ36.88 Encounter for antenatal screening for fetal macrosomiaZ36.81 Encounter for antenatal screening for hydrops fetalisZ36.5 Encounter for antenatal screening for isoimmunizationZ36.3 Encounter for antenatal screening for malformationsZ36.82 Encounter for antenatal screening for nuchal translucencyZ36.8A Encounter for antenatal screening for other genetic defectsZ36.1 Encounter for antenatal screening for raised alphafetoprotein levelZ36.85 Encounter for antenatal screening for Streptococcus BZ36.87 Encounter for antenatal screening for uncertain datesZ36.9 Encounter for antenatal screening, unspecifiedZ13.41 Encounter for autism screeningZ02.83 Encounter for blood-alcohol and blood-drug testZ41.1 Encounter for cosmetic surgeryZ02.71 Encounter for disability determinationZ41.3 Encounter for ear piercingZ04.89 Encounter for examination and observation for other specified reasonsZ04.9 Encounter for examination and observation for unspecified reasonZ04.82 Encounter for examination and observation of victim following forced labor

exploitationZ04.81 Encounter for examination and observation of victim following forced sexual

exploitationZ02.0 Encounter for examination for admission to educational institutionZ02.2 Encounter for examination for admission to residential institutionZ02.4 Encounter for examination for driving licenseZ02.6 Encounter for examination for insurance purposesZ00.6 Encounter for examination for normal comparison and control in clinical research

programZ02.5 Encounter for examination for participation in sportZ00.71 Encounter for examination for period of delayed growth in childhood with

abnormal findingsZ00.70 Encounter for examination for period of delayed growth in childhood without

abnormal findingsZ02.3 Encounter for examination for recruitment to armed forcesZ00.5 Encounter for examination of potential donor of organ and tissueZ36.83 Encounter for fetal screening for congenital cardiac abnormalitiesZ46.1 Encounter for fitting and adjustment of hearing aidZ00.01 Encounter for general adult medical examination with abnormal findingsZ00.00 Encounter for general adult medical examination without abnormal findingsZ04.6 Encounter for general psychiatric examination, requested by authorityZ76.1 Encounter for health supervision and care of foundlingZ76.2 Encounter for health supervision and care of other healthy infant and childZ02.79 Encounter for issue of other medical certificateZ76.0 Encounter for issue of repeat prescriptionZ13.71 Encounter for nonprocreative screening for genetic disease carrier statusZ02.89 Encounter for other administrative examinationsZ36.2 Encounter for other antenatal screening follow-upZ00.8 Encounter for other general examination

Z41.8 Encounter for other procedures for purposes other than remedying health stateZ40.8 Encounter for other prophylactic surgeryZ13.79 Encounter for other screening for genetic and chromosomal anomaliesZ36.89 Encounter for other specified antenatal screeningZ02.81 Encounter for paternity testingZ02.1 Encounter for pre-employment examinationZ41.9 Encounter for procedure for purposes other than remedying health state,

unspecifiedZ40.01 Encounter for prophylactic removal of breastZ40.09 Encounter for prophylactic removal of other organZ40.02 Encounter for prophylactic removal of ovary(s)Z40.00 Encounter for prophylactic removal of unspecified organZ40.9 Encounter for prophylactic surgery, unspecifiedZ41.2 Encounter for routine and ritual male circumcisionZ00.121 Encounter for routine child health examination with abnormal findingsZ00.129 Encounter for routine child health examination without abnormal findingsZ13.30 Encounter for screening examination for mental health and behavioral disorders,

unspecifiedZ13.39 Encounter for screening examination for other mental health and behavioral

disordersZ13.84 Encounter for screening for dental disordersZ13.31 Encounter for screening for depressionZ13.0 Encounter for screening for diseases of the blood and blood-forming organs and

certain disorders involving the immune mechanismZ13.88 Encounter for screening for disorder due to exposure to contaminantsZ13.5 Encounter for screening for eye and ear disordersZ13.42 Encounter for screening for global developmental delays (milestones)Z11.4 Encounter for screening for human immunodeficiency virus [HIV]Z11.51 Encounter for screening for human papillomavirus (HPV)Z11.3 Encounter for screening for infections with a predominantly sexual mode of

transmissionZ11.9 Encounter for screening for infectious and parasitic diseases, unspecifiedZ11.0 Encounter for screening for intestinal infectious diseasesZ13.220 Encounter for screening for lipoid disordersZ13.811 Encounter for screening for lower gastrointestinal disorderZ12.6 Encounter for screening for malignant neoplasm of bladderZ12.10 Encounter for screening for malignant neoplasm of intestinal tract, unspecifiedZ12.82 Encounter for screening for malignant neoplasm of nervous systemZ12.81 Encounter for screening for malignant neoplasm of oral cavityZ12.79 Encounter for screening for malignant neoplasm of other genitourinary organsZ12.89 Encounter for screening for malignant neoplasm of other sitesZ12.73 Encounter for screening for malignant neoplasm of ovaryZ12.2 Encounter for screening for malignant neoplasm of respiratory organsZ12.83 Encounter for screening for malignant neoplasm of skinZ12.13 Encounter for screening for malignant neoplasm of small intestineZ12.0 Encounter for screening for malignant neoplasm of stomachZ12.71 Encounter for screening for malignant neoplasm of testisZ12.72 Encounter for screening for malignant neoplasm of vaginaZ12.9 Encounter for screening for malignant neoplasm, site unspecifiedZ13.32 Encounter for screening for maternal depressionZ13.21 Encounter for screening for nutritional disorderZ13.820 Encounter for screening for osteoporosisZ11.2 Encounter for screening for other bacterial diseasesZ13.49 Encounter for screening for other developmental delaysZ13.818 Encounter for screening for other digestive system disordersZ13.89 Encounter for screening for other disorder

Compiled: 12/2019


Alpha Sort—Continued


Z83.6 Family history of other diseases of the respiratory systemZ83.49 Family history of other endocrine, nutritional and metabolic diseasesZ83.1 Family history of other infectious and parasitic diseasesZ80.7 Family history of other malignant neoplasms of lymphoid, hematopoietic and

related tissuesZ81.8 Family history of other mental and behavioral disordersZ81.3 Family history of other psychoactive substance abuse and dependenceZ84.89 Family history of other specified conditionsZ83.518 Family history of other specified eye disorderZ81.4 Family history of other substance abuse and dependenceZ82.71 Family history of polycystic kidneyZ82.3 Family history of strokeZ82.41 Family history of sudden cardiac deathZ81.2 Family history of tobacco abuse and dependenceZ00.111 Health examination for newborn 8 to 28 days oldZ00.110 Health examination for newborn under 8 days oldZ76.3 Healthy person accompanying sick personZ75.5 Holiday relief careZ59.0 HomelessnessR99 Ill-defined and unknown cause of mortalityZ59.1 Inadequate housingZ59.7 Insufficient social insurance and welfare supportZ59.4 Lack of adequate food and safe drinking waterZ59.6 Low incomeZ56.82 Military deployment statusZ74.2 Need for assistance at home and no other household member able to render careZ74.1 Need for assistance with personal careZ74.3 Need for continuous supervisionZ57.2 Occupational exposure to dustZ57.31 Occupational exposure to environmental tobacco smokeZ57.6 Occupational exposure to extreme temperatureZ57.0 Occupational exposure to noiseZ57.39 Occupational exposure to other air contaminantsZ57.8 Occupational exposure to other risk factorsZ57.1 Occupational exposure to radiationZ57.4 Occupational exposure to toxic agents in agricultureZ57.5 Occupational exposure to toxic agents in other industriesZ57.9 Occupational exposure to unspecified risk factorZ57.7 Occupational exposure to vibrationZ76.4 Other boarder to healthcare facilityZ56.6 Other physical and mental strain related to workZ74.8 Other problems related to care provider dependencyZ56.89 Other problems related to employmentZ59.8 Other problems related to housing and economic circumstancesZ71.0 Person encountering health services to consult on behalf of another personZ74.9 Problem related to care provider dependency, unspecifiedZ59.9 Problem related to housing and economic circumstances, unspecifiedZ60.2 Problems related to living aloneZ59.3 Problems related to living in residential institutionZ56.81 Sexual harassment on the jobZ56.3 Stressful work scheduleZ56.2 Threat of job lossZ56.5 Uncongenial work environmentZ56.0 Unemployment, unspecifiedZ56.9 Unspecified problems related to employment

Z11.8 Encounter for screening for other infectious and parasitic diseasesZ13.228 Encounter for screening for other metabolic disordersZ13.828 Encounter for screening for other musculoskeletal disorderZ13.858 Encounter for screening for other nervous system disordersZ11.6 Encounter for screening for other protozoal diseases and helminthiasesZ13.29 Encounter for screening for other suspected endocrine disorderZ11.59 Encounter for screening for other viral diseasesZ13.83 Encounter for screening for respiratory disorder NECZ11.1 Encounter for screening for respiratory tuberculosisZ13.850 Encounter for screening for traumatic brain injuryZ13.40 Encounter for screening for unspecified developmental delaysZ13.810 Encounter for screening for upper gastrointestinal disorderZ13.9 Encounter for screening, unspecifiedZ11.7 Encounter for testing for latent tuberculosis infectionZ76.81 Expectant parent(s) prebirth pediatrician visitZ59.5 Extreme povertyZ81.1 Family history of alcohol abuse and dependenceZ82.61 Family history of arthritisZ82.5 Family history of asthma and other chronic lower respiratory diseasesZ82.1 Family history of blindness and visual lossZ84.81 Family history of carrier of genetic diseaseZ83.71 Family history of colonic polypsZ84.3 Family history of consanguinityZ82.2 Family history of deafness and hearing lossZ83.3 Family history of diabetes mellitusZ83.2 Family history of diseases of the blood and blood-forming organs and certain

disorders involving the immune mechanismZ84.0 Family history of diseases of the skin and subcutaneous tissueZ84.1 Family history of disorders of kidney and ureterZ83.52 Family history of ear disordersZ82.0 Family history of epilepsy and other diseases of the nervous systemZ83.511 Family history of glaucomaZ83.0 Family history of human immunodeficiency virus [HIV] diseaseZ81.0 Family history of intellectual disabilitiesZ82.49 Family history of ischemic heart disease and other diseases of the circulatory

systemZ80.6 Family history of leukemiaZ80.52 Family history of malignant neoplasm of bladderZ80.51 Family history of malignant neoplasm of kidneyZ80.49 Family history of malignant neoplasm of other genital organsZ80.8 Family history of malignant neoplasm of other organs or systemsZ80.2 Family history of malignant neoplasm of other respiratory and intrathoracic

organsZ80.59 Family history of malignant neoplasm of other urinary tract organZ80.1 Family history of malignant neoplasm of trachea, bronchus and lungZ80.9 Family history of malignant neoplasm, unspecifiedZ83.41 Family history of multiple endocrine neoplasia [MEN] syndromeZ82.62 Family history of osteoporosisZ82.79 Family history of other congenital malformations, deformations and chromosomal

abnormalitiesZ82.8 Family history of other disabilities and chronic diseases leading to disablement,

not elsewhere classifiedZ83.79 Family history of other diseases of the digestive systemZ84.2 Family history of other diseases of the genitourinary systemZ82.69 Family history of other diseases of the musculoskeletal system and connective

tissue

Compiled: 12/2019



R99Z00.00Z00.01Z00.110Z00.111Z00.121Z00.129Z00.5Z00.6Z00.70Z00.71Z00.8Z02.0Z02.1Z02.2Z02.3Z02.4Z02.5Z02.6Z02.71Z02.79Z02.81Z02.82Z02.83Z02.89Z02.9Z04.6Z04.81Z04.82Z04.89Z04.9Z11.0Z11.1Z11.2Z11.3Z11.4Z11.51Z11.59Z11.6Z11.7Z11.8Z11.9Z12.0Z12.10Z12.13Z12.2Z12.6Z12.71Z12.72Z12.73Z12.79Z12.81Z12.82Z12.83Z12.89

Z12.9Z13.0Z13.21Z13.220Z13.228Z13.29Z13.30Z13.31Z13.32Z13.39Z13.40Z13.41Z13.42Z13.49Z13.5Z13.71Z13.79Z13.810Z13.811Z13.818Z13.820Z13.828Z13.83Z13.84Z13.850Z13.858Z13.88Z13.89Z13.9Z36.0Z36.1Z36.2Z36.3Z36.4Z36.5Z36.81Z36.82Z36.83Z36.84Z36.85Z36.86Z36.87Z36.88Z36.89Z36.8AZ36.9Z40.00Z40.01Z40.02Z40.09Z40.8Z40.9Z41.1Z41.2Z41.3

Z41.8Z41.9Z46.1Z56.0Z56.2Z56.3Z56.4Z56.5Z56.6Z56.81Z56.82Z56.89Z56.9Z57.0Z57.1Z57.2Z57.31Z57.39Z57.4Z57.5Z57.6Z57.7Z57.8Z57.9Z59.0Z59.1Z59.2Z59.3Z59.4Z59.5Z59.6Z59.7Z59.8Z59.9Z60.2Z62.21Z71.0Z74.1Z74.2Z74.3Z74.8Z74.9Z75.5Z76.0Z76.1Z76.2Z76.3Z76.4Z76.81Z80.1Z80.2Z80.49Z80.51Z80.52Z80.59

Z80.6Z80.7Z80.8Z80.9Z81.0Z81.1Z81.2Z81.3Z81.4Z81.8Z82.0Z82.1Z82.2Z82.3Z82.41Z82.49Z82.5Z82.61Z82.62Z82.69Z82.71Z82.79Z82.8Z83.0Z83.1Z83.2Z83.3Z83.41Z83.49Z83.511Z83.518Z83.52Z83.6Z83.71Z83.79Z84.0Z84.1Z84.2Z84.3Z84.81Z84.89

Numeric Sort

Compiled: 12/2019

LIMITATIONS:

The following tests are considered not medically reasonable and necessary

• Provocative testing other than those mentioned above• Blood, Urine or Stool micronutrient assessments• Qualification of Nutritional Assessments• IgG (ELISA) test• Environmental Cultures and Chemicals• Live Cell Analysis• Passive Transfer• Rebuck Skin Window• Leukocyte Histamine Release• Metabolic Assessments• General Immune System Assessments• Secretory IgA (Saliva)• Qualitative multi-allergen screen• Food Allergenic Extract Immunotherapy• Cytotoxic Food Testing

Allergen specific IgE; qualitative, multiallergen screen is a non-specific screen that does not identify a specific antigen. This is a screening tool and therefore not covered by Medicare.

NCD 110.11 outlines limitations for food allergy testing and treatment. Refer to CMS Manual System, Pub 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 2, Section 110.11 for details.

Allergen-specific IgG and IgG subclasses measured by using immunoabsorption assays and IgG and IgG subclass antibody tests for food allergy/delayed food allergy /delayed food allergic symptoms or intolerance to specific foods are considered experimental and investigational, as there is insufficient evidence in the published peer-reviewed scientific literature to support the diagnostic value of these tests for allergy testing.

In-vitro testing is covered when medically reasonable and necessary as a substitute for skin testing; it is not usually necessary in addition to skin testing

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

The number of tests performed should be judicious. All patients should not necessarily be tested for the same antigens.

Medicare is establishing the following limited coverage for CPT codes 86003 and 86008:

J34.0 Abscess, furuncle and carbuncle of noseH10.13 Acute atopic conjunctivitis, bilateralH10.12 Acute atopic conjunctivitis, left eyeH10.11 Acute atopic conjunctivitis, right eyeJ20.3 Acute bronchitis due to coxsackievirusJ20.7 Acute bronchitis due to echovirus

J20.1 Acute bronchitis due to Hemophilus influenzaeJ20.0 Acute bronchitis due to Mycoplasma pneumoniaeJ20.8 Acute bronchitis due to other specified organismsJ20.4 Acute bronchitis due to parainfluenza virusJ20.5 Acute bronchitis due to respiratory syncytial virusJ20.6 Acute bronchitis due to rhinovirusJ20.2 Acute bronchitis due to streptococcusJ04.0 Acute laryngitisJ05.0 Acute obstructive laryngitis [croup]J02.8 Acute pharyngitis due to other specified organismsJ01.21 Acute recurrent ethmoidal sinusitisJ01.11 Acute recurrent frontal sinusitisJ01.01 Acute recurrent maxillary sinusitisJ01.41 Acute recurrent pansinusitisJ01.91 Acute recurrent sinusitis, unspecifiedJ01.31 Acute recurrent sphenoidal sinusitisJ03.91 Acute recurrent tonsillitis, unspecifiedH65.06 Acute serous otitis media, recurrent, bilateralH65.05 Acute serous otitis media, recurrent, left earH65.04 Acute serous otitis media, recurrent, right earT39.1X5A Adverse effect of 4-Aminophenol derivatives, initial encounterT39.1X5S Adverse effect of 4-Aminophenol derivatives, sequelaT39.1X5D Adverse effect of 4-Aminophenol derivatives, subsequent encounterT45.0X5A Adverse effect of antiallergic and antiemetic drugs, initial encounterT45.0X5S Adverse effect of antiallergic and antiemetic drugs, sequelaT45.0X5D Adverse effect of antiallergic and antiemetic drugs, subsequent encounterT39.015A Adverse effect of aspirin, initial encounterT39.015S Adverse effect of aspirin, sequelaT39.015D Adverse effect of aspirin, subsequent encounterT36.1X5A Adverse effect of cephalosporins and other beta-lactam antibiotics, initial

encounterT36.1X5S Adverse effect of cephalosporins and other beta-lactam antibiotics, sequelaT36.1X5D Adverse effect of cephalosporins and other beta-lactam antibiotics, subsequent

encounterT50.995A Adverse effect of other drugs, medicaments and biological substances, initial

encounterT50.995S Adverse effect of other drugs, medicaments and biological substances, sequelaT50.995D Adverse effect of other drugs, medicaments and biological substances, subsequent

encounterT37.8X5A Adverse effect of other specified systemic anti-infectives and antiparasitics, initial

encounterT37.8X5S Adverse effect of other specified systemic anti-infectives and antiparasitics,

sequelaT37.8X5D Adverse effect of other specified systemic anti-infectives and antiparasitics,

subsequent encounterT36.8X5A Adverse effect of other systemic antibiotics, initial encounterT36.8X5S Adverse effect of other systemic antibiotics, sequelaT36.8X5D Adverse effect of other systemic antibiotics, subsequent encounterT36.0X5A Adverse effect of penicillins, initial encounterT36.0X5S Adverse effect of penicillins, sequelaT36.0X5D Adverse effect of penicillins, subsequent encounterT37.0X5A Adverse effect of sulfonamides, initial encounterT37.0X5S Adverse effect of sulfonamides, sequelaT37.0X5D Adverse effect of sulfonamides, subsequent encounterT36.4X5A Adverse effect of tetracyclines, initial encounterT36.4X5S Adverse effect of tetracyclines, sequelaT36.4X5D Adverse effect of tetracyclines, subsequent encounter

Alpha Sort

82785, 86001, 86003, 86005, 86008

Allergy Testing

Novitas Solutions, Inc. — Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania Compiled: 12/2019

Novitas Solutions, Inc. — Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania

Allergy Testing82785, 86001, 86003, 86005, 86008

Alpha Sort —ContinuedT78.01XD Anaphylactic reaction due to peanuts, subsequent encounterT78.02XA Anaphylactic reaction due to shellfish (crustaceans), initial encounterT78.02XS Anaphylactic reaction due to shellfish (crustaceans), sequelaT78.02XD Anaphylactic reaction due to shellfish (crustaceans), subsequent encounterT78.05XA Anaphylactic reaction due to tree nuts and seeds, initial encounterT78.05XS Anaphylactic reaction due to tree nuts and seeds, sequelaT78.05XD Anaphylactic reaction due to tree nuts and seeds, subsequent encounterT78.00XA Anaphylactic reaction due to unspecified food, initial encounterT78.00XS Anaphylactic reaction due to unspecified food, sequelaT78.00XD Anaphylactic reaction due to unspecified food, subsequent encounterT80.52XA Anaphylactic reaction due to vaccination, initial encounterT80.52XS Anaphylactic reaction due to vaccination, sequelaT80.52XD Anaphylactic reaction due to vaccination, subsequent encounterT78.2XXA Anaphylactic shock, unspecified, initial encounterT78.2XXS Anaphylactic shock, unspecified, sequelaT78.2XXD Anaphylactic shock, unspecified, subsequent encounterT78.3XXA Angioneurotic edema, initial encounterT78.3XXS Angioneurotic edema, sequelaT78.3XXD Angioneurotic edema, subsequent encounterL20.81 Atopic neurodermatitisZ91.030 Bee allergy statusL20.0 Besnier’s prurigoH65.413 Chronic allergic otitis media, bilateralH65.412 Chronic allergic otitis media, left earH65.411 Chronic allergic otitis media, right earJ32.2 Chronic ethmoidal sinusitisJ32.1 Chronic frontal sinusitisH10.413 Chronic giant papillary conjunctivitis, bilateralH10.412 Chronic giant papillary conjunctivitis, left eyeH10.411 Chronic giant papillary conjunctivitis, right eyeJ32.0 Chronic maxillary sinusitisJ44.1 Chronic obstructive pulmonary disease with (acute) exacerbationJ44.0 Chronic obstructive pulmonary disease with (acute) lower respiratory infectionJ44.9 Chronic obstructive pulmonary disease, unspecifiedJ31.0 Chronic rhinitisK29.30 Chronic superficial gastritis without bleedingL50.6 Contact urticariaR05 CoughJ45.991 Cough variant asthmaJ34.1 Cyst and mucocele of nose and nasal sinusL27.2 Dermatitis due to ingested foodR06.00 Dyspnea, unspecifiedJ45.990 Exercise induced bronchospasmL20.82 Flexural eczemaJ34.3 Hypertrophy of nasal turbinatesL50.1 Idiopathic urticariaL20.84 Intrinsic (allergic) eczemaZ91.040 Latex allergy statusJ45.21 Mild intermittent asthma with (acute) exacerbationJ45.22 Mild intermittent asthma with status asthmaticusJ45.20 Mild intermittent asthma, uncomplicatedJ45.31 Mild persistent asthma with (acute) exacerbationJ45.32 Mild persistent asthma with status asthmaticusJ45.30 Mild persistent asthma, uncomplicatedJ45.41 Moderate persistent asthma with (acute) exacerbation

T50.905A Adverse effect of unspecified drugs, medicaments and biological substances, initial encounter

T50.905S Adverse effect of unspecified drugs, medicaments and biological substances, sequela

T50.905D Adverse effect of unspecified drugs, medicaments and biological substances, subsequent encounter

J30.81 Allergic rhinitis due to animal (cat) (dog) hair and danderJ30.1 Allergic rhinitis due to pollenJ30.9 Allergic rhinitis, unspecifiedL50.0 Allergic urticariaZ88.6 Allergy status to analgesic agent statusZ88.4 Allergy status to anesthetic agent statusZ88.5 Allergy status to narcotic agent statusZ88.1 Allergy status to other antibiotic agents statusZ88.3 Allergy status to other anti-infective agents statusZ88.8 Allergy status to other drugs, medicaments and biological substances statusZ88.0 Allergy status to penicillinZ88.7 Allergy status to serum and vaccine statusZ88.2 Allergy status to sulfonamides statusZ88.9 Allergy status to unspecified drugs, medicaments and biological substances statusZ91.012 Allergy to eggsZ91.011 Allergy to milk productsZ91.018 Allergy to other foodsZ91.010 Allergy to peanutsZ91.013 Allergy to seafoodT80.51XA Anaphylactic reaction due to administration of blood and blood products, initial

encounterT80.51XS Anaphylactic reaction due to administration of blood and blood products, sequelaT80.51XD Anaphylactic reaction due to administration of blood and blood products,

subsequent encounterT78.08XA Anaphylactic reaction due to eggs, initial encounterT78.08XS Anaphylactic reaction due to eggs, sequelaT78.08XD Anaphylactic reaction due to eggs, subsequent encounterT78.06XA Anaphylactic reaction due to food additives, initial encounterT78.06XS Anaphylactic reaction due to food additives, sequelaT78.06XD Anaphylactic reaction due to food additives, subsequent encounterT78.04XA Anaphylactic reaction due to fruits and vegetables, initial encounterT78.04XS Anaphylactic reaction due to fruits and vegetables, sequelaT78.04XD Anaphylactic reaction due to fruits and vegetables, subsequent encounterT78.07XA Anaphylactic reaction due to milk and dairy products, initial encounterT78.07XS Anaphylactic reaction due to milk and dairy products, sequelaT78.07XD Anaphylactic reaction due to milk and dairy products, subsequent encounterT78.03XA Anaphylactic reaction due to other fish, initial encounterT78.03XS Anaphylactic reaction due to other fish, sequelaT78.03XD Anaphylactic reaction due to other fish, subsequent encounterT78.09XA Anaphylactic reaction due to other food products, initial encounterT78.09XS Anaphylactic reaction due to other food products, sequelaT78.09XD Anaphylactic reaction due to other food products, subsequent encounterT80.59XA Anaphylactic reaction due to other serum, initial encounterT80.59XS Anaphylactic reaction due to other serum, sequelaT80.59XD Anaphylactic reaction due to other serum, subsequent encounterT78.01XA Anaphylactic reaction due to peanuts, initial encounterT78.01XS Anaphylactic reaction due to peanuts, sequela

Medicare is establishing the following limited coverage for CPT codes 86003 and 86008—Continued:

Compiled: 12/2019


Allergy Testing82785, 86001, 86003, 86005, 86008

Alpha Sort—ContinuedM02.211 Postimmunization arthropathy, right shoulderM02.231 Postimmunization arthropathy, right wristM02.28 Postimmunization arthropathy, vertebraeL29.9 Pruritus, unspecifiedZ91.041 Radiographic dye allergy statusJ45.51 Severe persistent asthma with (acute) exacerbationJ45.52 Severe persistent asthma with status asthmaticusJ45.50 Severe persistent asthma, uncomplicatedR06.83 SnoringJ04.31 Supraglottitis, unspecified, with obstructionJ04.30 Supraglottitis, unspecified, without obstructionT63.91XA Toxic effect of contact with unspecified venomous animal, accidental

(unintentional), initial encounterT63.91XS Toxic effect of contact with unspecified venomous animal, accidental

(unintentional), sequelaT63.91XD Toxic effect of contact with unspecified venomous animal, accidental

(unintentional), subsequent encounterT63.93XA Toxic effect of contact with unspecified venomous animal, assault, initial

encounterT63.93XS Toxic effect of contact with unspecified venomous animal, assault, sequelaT63.93XD Toxic effect of contact with unspecified venomous animal, assault, subsequent

encounterT63.92XA Toxic effect of contact with unspecified venomous animal, intentional self-harm,

initial encounterT63.92XS Toxic effect of contact with unspecified venomous animal, intentional self-harm,

sequelaT63.92XD Toxic effect of contact with unspecified venomous animal, intentional self-harm,

subsequent encounterT63.94XA Toxic effect of contact with unspecified venomous animal, undetermined, initial

encounterT63.94XS Toxic effect of contact with unspecified venomous animal, undetermined, sequelaT63.94XD Toxic effect of contact with unspecified venomous animal, undetermined,

subsequent encounterT63.421A Toxic effect of venom of ants, accidental (unintentional), initial encounterT63.421S Toxic effect of venom of ants, accidental (unintentional), sequelaT63.421D Toxic effect of venom of ants, accidental (unintentional), subsequent encounterT63.423A Toxic effect of venom of ants, assault, initial encounterT63.423S Toxic effect of venom of ants, assault, sequelaT63.423D Toxic effect of venom of ants, assault, subsequent encounterT63.422A Toxic effect of venom of ants, intentional self-harm, initial encounterT63.422S Toxic effect of venom of ants, intentional self-harm, sequelaT63.422D Toxic effect of venom of ants, intentional self-harm, subsequent encounterT63.424A Toxic effect of venom of ants, undetermined, initial encounterT63.424S Toxic effect of venom of ants, undetermined, sequelaT63.424D Toxic effect of venom of ants, undetermined, subsequent encounterT63.441A Toxic effect of venom of bees, accidental (unintentional), initial encounterT63.441S Toxic effect of venom of bees, accidental (unintentional), sequelaT63.441D Toxic effect of venom of bees, accidental (unintentional), subsequent encounterT63.443A Toxic effect of venom of bees, assault, initial encounterT63.443S Toxic effect of venom of bees, assault, sequelaT63.443D Toxic effect of venom of bees, assault, subsequent encounterT63.442A Toxic effect of venom of bees, intentional self-harm, initial encounterT63.442S Toxic effect of venom of bees, intentional self-harm, sequelaT63.442D Toxic effect of venom of bees, intentional self-harm, subsequent encounterT63.444A Toxic effect of venom of bees, undetermined, initial encounterT63.444S Toxic effect of venom of bees, undetermined, sequela

J45.42 Moderate persistent asthma with status asthmaticusJ45.40 Moderate persistent asthma, uncomplicatedR09.81 Nasal congestionJ33.9 Nasal polyp, unspecifiedR06.89 Other abnormalities of breathingJ01.81 Other acute recurrent sinusitisJ30.89 Other allergic rhinitisZ91.09 Other allergy status, other than to drugs and biological substancesT78.49XA Other allergy, initial encounterT78.49XS Other allergy, sequelaT78.49XD Other allergy, subsequent encounterJ45.998 Other asthmaL20.89 Other atopic dermatitisH10.45 Other chronic allergic conjunctivitisH65.493 Other chronic nonsuppurative otitis media, bilateralH65.492 Other chronic nonsuppurative otitis media, left earH65.491 Other chronic nonsuppurative otitis media, right earR06.09 Other forms of dyspneaK29.60 Other gastritis without bleedingZ91.038 Other insect allergy statusZ91.048 Other nonmedicinal substance allergy statusJ33.8 Other polyp of sinusJ30.2 Other seasonal allergic rhinitisT80.61XA Other serum reaction due to administration of blood and blood products, initial

encounterT80.61XS Other serum reaction due to administration of blood and blood products, sequelaT80.61XD Other serum reaction due to administration of blood and blood products,

subsequent encounterT80.69XA Other serum reaction due to other serum, initial encounterT80.69XS Other serum reaction due to other serum, sequelaT80.69XD Other serum reaction due to other serum, subsequent encounterT80.62XA Other serum reaction due to vaccination, initial encounterT80.62XS Other serum reaction due to vaccination, sequelaT80.62XD Other serum reaction due to vaccination, subsequent encounterJ34.89 Other specified disorders of nose and nasal sinusesL50.8 Other urticariaH66.93 Otitis media, unspecified, bilateralH66.92 Otitis media, unspecified, left earH66.91 Otitis media, unspecified, right earJ33.0 Polyp of nasal cavityM02.272 Postimmunization arthropathy, left ankle and footM02.222 Postimmunization arthropathy, left elbowM02.242 Postimmunization arthropathy, left handM02.252 Postimmunization arthropathy, left hipM02.262 Postimmunization arthropathy, left kneeM02.212 Postimmunization arthropathy, left shoulderM02.232 Postimmunization arthropathy, left wristM02.29 Postimmunization arthropathy, multiple sitesM02.271 Postimmunization arthropathy, right ankle and footM02.221 Postimmunization arthropathy, right elbowM02.241 Postimmunization arthropathy, right handM02.251 Postimmunization arthropathy, right hipM02.261 Postimmunization arthropathy, right knee


Compiled: 12/2019


Allergy Testing82785, 86001, 86003, 86005, 86008

Alpha Sort—ContinuedH10.33 Unspecified acute conjunctivitis, bilateralH10.32 Unspecified acute conjunctivitis, left eyeH10.31 Unspecified acute conjunctivitis, right eyeJ45.901 Unspecified asthma with (acute) exacerbationJ45.902 Unspecified asthma with status asthmaticusL50.9 Urticaria, unspecifiedJ30.0 Vasomotor rhinitisH10.44 Vernal conjunctivitis

T63.444D Toxic effect of venom of bees, undetermined, subsequent encounterT63.431A Toxic effect of venom of caterpillars, accidental (unintentional), initial encounterT63.431S Toxic effect of venom of caterpillars, accidental (unintentional), sequelaT63.431D Toxic effect of venom of caterpillars, accidental (unintentional), subsequent

encounterT63.433A Toxic effect of venom of caterpillars, assault, initial encounterT63.433S Toxic effect of venom of caterpillars, assault, sequelaT63.433D Toxic effect of venom of caterpillars, assault, subsequent encounterT63.432A Toxic effect of venom of caterpillars, intentional self-harm, initial encounterT63.432S Toxic effect of venom of caterpillars, intentional self-harm, sequelaT63.432D Toxic effect of venom of caterpillars, intentional self-harm, subsequent encounterT63.434A Toxic effect of venom of caterpillars, undetermined, initial encounterT63.434S Toxic effect of venom of caterpillars, undetermined, sequelaT63.434D Toxic effect of venom of caterpillars, undetermined, subsequent encounterT63.451A Toxic effect of venom of hornets, accidental (unintentional), initial encounterT63.451S Toxic effect of venom of hornets, accidental (unintentional), sequelaT63.451D Toxic effect of venom of hornets, accidental (unintentional), subsequent encounterT63.453A Toxic effect of venom of hornets, assault, initial encounterT63.453S Toxic effect of venom of hornets, assault, sequelaT63.453D Toxic effect of venom of hornets, assault, subsequent encounterT63.452A Toxic effect of venom of hornets, intentional self-harm, initial encounterT63.452S Toxic effect of venom of hornets, intentional self-harm, sequelaT63.452D Toxic effect of venom of hornets, intentional self-harm, subsequent encounterT63.454A Toxic effect of venom of hornets, undetermined, initial encounterT63.454S Toxic effect of venom of hornets, undetermined, sequelaT63.454D Toxic effect of venom of hornets, undetermined, subsequent encounterT63.481A Toxic effect of venom of other arthropod, accidental (unintentional), initial

encounterT63.481S Toxic effect of venom of other arthropod, accidental (unintentional), sequelaT63.481D Toxic effect of venom of other arthropod, accidental (unintentional), subsequent

encounterT63.483A Toxic effect of venom of other arthropod, assault, initial encounterT63.483S Toxic effect of venom of other arthropod, assault, sequelaT63.483D Toxic effect of venom of other arthropod, assault, subsequent encounterT63.482A Toxic effect of venom of other arthropod, intentional self-harm, initial encounterT63.482S Toxic effect of venom of other arthropod, intentional self-harm, sequelaT63.482D Toxic effect of venom of other arthropod, intentional self-harm, subsequent

encounterT63.484A Toxic effect of venom of other arthropod, undetermined, initial encounterT63.484S Toxic effect of venom of other arthropod, undetermined, sequelaT63.484D Toxic effect of venom of other arthropod, undetermined, subsequent encounterT63.461A Toxic effect of venom of wasps, accidental (unintentional), initial encounterT63.461S Toxic effect of venom of wasps, accidental (unintentional), sequelaT63.461D Toxic effect of venom of wasps, accidental (unintentional), subsequent encounterT63.463A Toxic effect of venom of wasps, assault, initial encounterT63.463S Toxic effect of venom of wasps, assault, sequelaT63.463D Toxic effect of venom of wasps, assault, subsequent encounterT63.462A Toxic effect of venom of wasps, intentional self-harm, initial encounterT63.462S Toxic effect of venom of wasps, intentional self-harm, sequelaT63.462D Toxic effect of venom of wasps, intentional self-harm, subsequent encounterT63.464A Toxic effect of venom of wasps, undetermined, initial encounterT63.464S Toxic effect of venom of wasps, undetermined, sequelaT63.464D Toxic effect of venom of wasps, undetermined, subsequent encounter


Numeric Sort

H10.11H10.12H10.13H10.31H10.32H10.33H10.411H10.412H10.413H10.44H10.45H65.04H65.05H65.06H65.411H65.412H65.413H65.491H65.492H65.493H66.91H66.92H66.93J01.01J01.11J01.21J01.31J01.41J01.81J01.91J02.8J03.91J04.0J04.30J04.31J05.0J20.0J20.1J20.2J20.3J20.4J20.5J20.6J20.7

J20.8J30.0J30.1J30.2J30.81J30.89J30.9J31.0J32.0J32.1J32.2J33.0J33.8J33.9J34.0J34.1J34.3J34.89J44.0J44.1J44.9J45.20J45.21J45.22J45.30J45.31J45.32J45.40J45.41J45.42J45.50J45.51J45.52J45.901J45.902J45.990J45.991J45.998K29.30K29.60L20.0L20.81L20.82L20.84

L20.89L27.2L29.9L50.0L50.1L50.6L50.8L50.9M02.211M02.212M02.221M02.222M02.231M02.232M02.241M02.242M02.251M02.252M02.261M02.262M02.271M02.272M02.28M02.29R05R06.00R06.09R06.83R06.89R09.81T36.0X5AT36.0X5DT36.0X5ST36.1X5AT36.1X5DT36.1X5ST36.4X5AT36.4X5DT36.4X5ST36.8X5AT36.8X5DT36.8X5ST37.0X5AT37.0X5D

T37.0X5ST37.8X5AT37.8X5DT37.8X5ST39.015AT39.015DT39.015ST39.1X5AT39.1X5DT39.1X5ST45.0X5AT45.0X5DT45.0X5ST50.905AT50.905DT50.905ST50.995AT50.995DT50.995ST63.421AT63.421DT63.421ST63.422AT63.422DT63.422ST63.423AT63.423DT63.423ST63.424AT63.424DT63.424ST63.431AT63.431DT63.431ST63.432AT63.432DT63.432ST63.433AT63.433DT63.433ST63.434AT63.434DT63.434ST63.441A

Compiled: 12/2019


Allergy Testing82785, 86001, 86003, 86005, 86008

Numeric Sort—Continued

T63.441DT63.441ST63.442AT63.442DT63.442ST63.443AT63.443DT63.443ST63.444AT63.444DT63.444ST63.451AT63.451DT63.451ST63.452AT63.452DT63.452ST63.453AT63.453DT63.453ST63.454AT63.454DT63.454ST63.461AT63.461DT63.461ST63.462AT63.462DT63.462ST63.463AT63.463DT63.463ST63.464AT63.464DT63.464S

T63.481AT63.481DT63.481ST63.482AT63.482DT63.482ST63.483AT63.483DT63.483ST63.484AT63.484DT63.484ST63.91XAT63.91XDT63.91XST63.92XAT63.92XDT63.92XST63.93XAT63.93XDT63.93XST63.94XAT63.94XDT63.94XST78.00XAT78.00XDT78.00XST78.01XAT78.01XDT78.01XST78.02XAT78.02XDT78.02XST78.03XAT78.03XD

T78.03XST78.04XAT78.04XDT78.04XST78.05XAT78.05XDT78.05XST78.06XAT78.06XDT78.06XST78.07XAT78.07XDT78.07XST78.08XAT78.08XDT78.08XST78.09XAT78.09XDT78.09XST78.2XXAT78.2XXDT78.2XXST78.3XXAT78.3XXDT78.3XXST78.49XAT78.49XDT78.49XST80.51XAT80.51XDT80.51XST80.52XAT80.52XDT80.52XST80.59XA

T80.59XDT80.59XST80.61XAT80.61XDT80.61XST80.62XAT80.62XDT80.62XST80.69XAT80.69XDT80.69XSZ88.0Z88.1Z88.2Z88.3Z88.4Z88.5Z88.6Z88.7Z88.8Z88.9Z91.010Z91.011Z91.012Z91.013Z91.018Z91.030Z91.038Z91.040Z91.041Z91.048Z91.09


Medicare is establishing the following limited coverage for CPT codes 82785, 86003 and 86008:

Alpha Sort

L50.0 Allergic urticariaT78.08XA Anaphylactic reaction due to eggs, initial encounterT78.08XS Anaphylactic reaction due to eggs, sequelaT78.08XD Anaphylactic reaction due to eggs, subsequent encounterT78.06XA Anaphylactic reaction due to food additives, initial encounterT78.06XS Anaphylactic reaction due to food additives, sequelaT78.06XD Anaphylactic reaction due to food additives, subsequent encounterT78.04XA Anaphylactic reaction due to fruits and vegetables, initial encounterT78.04XS Anaphylactic reaction due to fruits and vegetables, sequelaT78.04XD Anaphylactic reaction due to fruits and vegetables, subsequent encounterT78.07XA Anaphylactic reaction due to milk and dairy products, initial encounterT78.07XS Anaphylactic reaction due to milk and dairy products, sequelaT78.07XD Anaphylactic reaction due to milk and dairy products, subsequent encounterT78.03XA Anaphylactic reaction due to other fish, initial encounterT78.03XS Anaphylactic reaction due to other fish, sequelaT78.03XD Anaphylactic reaction due to other fish, subsequent encounterT78.09XA Anaphylactic reaction due to other food products, initial encounterT78.09XS Anaphylactic reaction due to other food products, sequelaT78.09XD Anaphylactic reaction due to other food products, subsequent encounterT78.01XA Anaphylactic reaction due to peanuts, initial encounterT78.01XS Anaphylactic reaction due to peanuts, sequelaT78.01XD Anaphylactic reaction due to peanuts, subsequent encounterT78.02XA Anaphylactic reaction due to shellfish (crustaceans), initial encounterT78.02XS Anaphylactic reaction due to shellfish (crustaceans), sequelaT78.02XD Anaphylactic reaction due to shellfish (crustaceans), subsequent encounterT78.05XA Anaphylactic reaction due to tree nuts and seeds, initial encounterT78.05XS Anaphylactic reaction due to tree nuts and seeds, sequelaT78.05XD Anaphylactic reaction due to tree nuts and seeds, subsequent encounterT78.00XA Anaphylactic reaction due to unspecified food, initial encounterT78.00XS Anaphylactic reaction due to unspecified food, sequelaT78.00XD Anaphylactic reaction due to unspecified food, subsequent encounterT78.2XXA Anaphylactic shock, unspecified, initial encounterT78.2XXS Anaphylactic shock, unspecified, sequelaT78.2XXD Anaphylactic shock, unspecified, subsequent encounterJ31.0 Chronic rhinitisL50.6 Contact urticariaJ45.991 Cough variant asthmaL50.3 Dermatographic urticariaZ09 Encounter for follow-up examination after completed treatment for conditions

other than malignant neoplasmJ45.990 Exercise induced bronchospasmL20.82 Flexural eczemaL50.1 Idiopathic urticariaL20.84 Intrinsic (allergic) eczemaB44.0 Invasive pulmonary aspergillosisJ45.21 Mild intermittent asthma with (acute) exacerbationJ45.22 Mild intermittent asthma with status asthmaticusJ45.20 Mild intermittent asthma, uncomplicatedJ45.31 Mild persistent asthma with (acute) exacerbationJ45.32 Mild persistent asthma with status asthmaticusJ45.30 Mild persistent asthma, uncomplicatedJ45.41 Moderate persistent asthma with (acute) exacerbationJ45.42 Moderate persistent asthma with status asthmaticus

Compiled: 12/2019


Allergy Testing82785, 86001, 86003, 86005, 86008

J45.40 Moderate persistent asthma, uncomplicatedJ45.998 Other asthmaL20.89 Other atopic dermatitisL50.8 Other urticariaZ86.19* Personal history of other infectious and parasitic diseasesJ45.51 Severe persistent asthma with (acute) exacerbationJ45.52 Severe persistent asthma with status asthmaticusJ45.50 Severe persistent asthma, uncomplicatedR06.02 Shortness of breathT63.91XA Toxic effect of contact with unspecified venomous animal, accidental

(unintentional), initial encounterT63.91XS Toxic effect of contact with unspecified venomous animal, accidental

(unintentional), sequelaT63.91XD Toxic effect of contact with unspecified venomous animal, accidental

(unintentional), subsequent encounterT63.93XA Toxic effect of contact with unspecified venomous animal, assault, initial

encounterT63.93XS Toxic effect of contact with unspecified venomous animal, assault, sequelaT63.93XD Toxic effect of contact with unspecified venomous animal, assault, subsequent

encounterT63.92XA Toxic effect of contact with unspecified venomous animal, intentional self-harm,

initial encounterT63.92XS Toxic effect of contact with unspecified venomous animal, intentional self-harm,

sequelaT63.92XD Toxic effect of contact with unspecified venomous animal, intentional self-harm,

subsequent encounterT63.94XA Toxic effect of contact with unspecified venomous animal, undetermined, initial

encounterT63.94XS Toxic effect of contact with unspecified venomous animal, undetermined, sequelaT63.94XD Toxic effect of contact with unspecified venomous animal, undetermined,

subsequent encounterT65.811A Toxic effect of latex, accidental (unintentional), initial encounterT65.811S Toxic effect of latex, accidental (unintentional), sequelaT65.811D Toxic effect of latex, accidental (unintentional), subsequent encounterT65.813A Toxic effect of latex, assault, initial encounterT65.813S Toxic effect of latex, assault, sequelaT65.813D Toxic effect of latex, assault, subsequent encounterT65.812A Toxic effect of latex, intentional self-harm, initial encounterT65.812S Toxic effect of latex, intentional self-harm, sequelaT65.812D Toxic effect of latex, intentional self-harm, subsequent encounterT65.814A Toxic effect of latex, undetermined, initial encounterT65.814S Toxic effect of latex, undetermined, sequelaT65.814D Toxic effect of latex, undetermined, subsequent encounterL50.9 Urticaria, unspecified

Note: Z86.19 Personal history of infectious and parasitic disease should be used for recurrent pyogenic infections.

Medicare is establishing the following limited coverage for CPT codes 82785, 86003 and 86008—Continued:

Alpha Sort—Continued Numeric SortB44.0J31.0J45.20J45.21J45.22J45.30J45.31J45.32J45.40J45.41J45.42J45.50J45.51J45.52J45.990J45.991J45.998L20.82L20.84L20.89L50.0L50.1L50.3L50.6L50.8L50.9R06.02T63.91XAT63.91XDT63.91XST63.92XAT63.92XDT63.92XST63.93XAT63.93XDT63.93XST63.94XAT63.94XDT63.94XST65.811AT65.811DT65.811ST65.812A

T65.812DT65.812ST65.813AT65.813DT65.813ST65.814AT65.814DT65.814ST78.00XAT78.00XDT78.00XST78.01XAT78.01XDT78.01XST78.02XAT78.02XDT78.02XST78.03XAT78.03XDT78.03XST78.04XAT78.04XDT78.04XST78.05XAT78.05XDT78.05XST78.06XAT78.06XDT78.06XST78.07XAT78.07XDT78.07XST78.08XAT78.08XDT78.08XST78.09XAT78.09XDT78.09XST78.2XXAT78.2XXDT78.2XXSZ09Z86.19*

Note: Z86.19 Personal history of infectious and parasitic disease should be used for recurrent pyogenic infections.

Compiled: 12/2019


Alpha-Fetoprotein82105

R93.1 Abnormal findings on diagnostic imaging of heart and coronary circulationR93.2 Abnormal findings on diagnostic imaging of liver and biliary tractR93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including

retroperitoneumR93.89 Abnormal findings on diagnostic imaging of other specified body structuresR93.812 Abnormal radiologic findings on diagnostic imaging of left testicleR93.811 Abnormal radiologic findings on diagnostic imaging of right testicleR93.813 Abnormal radiologic findings on diagnostic imaging of testicles, bilateralR93.819 Abnormal radiologic findings on diagnostic imaging of unspecified testicleK70.31 Alcoholic cirrhosis of liver with ascitesK70.30 Alcoholic cirrhosis of liver without ascitesK70.2 Alcoholic fibrosis and sclerosis of liverE88.01 Alpha-1-antitrypsin deficiencyC22.3 Angiosarcoma of liverK75.4 Autoimmune hepatitisN44.2 Benign cyst of testisD13.5 Benign neoplasm of extrahepatic bile ductsD13.4 Benign neoplasm of liverQ53.23 Bilateral high scrotal testesQ53.212 Bilateral inguinal testesQ53.211 Bilateral intraabdominal testesR39.84 Bilateral non-palpable testiclesD81.810 Biotinidase deficiencyK73.2 Chronic active hepatitis, not elsewhere classifiedK73.9 Chronic hepatitis, unspecifiedK73.1 Chronic lobular hepatitis, not elsewhere classifiedK73.0 Chronic persistent hepatitis, not elsewhere classifiedB18.0 Chronic viral hepatitis B with delta-agentB18.1 Chronic viral hepatitis B without delta-agentB18.2 Chronic viral hepatitis CB66.1 ClonorchiasisI25.84 Coronary atherosclerosis due to calcified coronary lesionN50.3 Cyst of epididymisN44.1 Cyst of tunica albuginea testisE84.19 Cystic fibrosis with other intestinal manifestationsE84.9 Cystic fibrosis, unspecifiedD84.1 Defects in the complement systemE83.00 Disorder of copper metabolism, unspecifiedE83.10 Disorder of iron metabolism, unspecifiedI74.19 Embolism and thrombosis of other parts of aortaI74.10 Embolism and thrombosis of unspecified parts of aortaZ13.41 Encounter for autism screeningZ04.89 Encounter for examination and observation for other specified reasonsZ04.82 Encounter for examination and observation of victim following forced labor

exploitationZ04.81 Encounter for examination and observation of victim following forced sexual

exploitationZ13.42 Encounter for screening for global developmental delays (milestones)Z13.49 Encounter for screening for other developmental delaysZ13.40 Encounter for screening for unspecified developmental delaysZ17.1 Estrogen receptor negative status [ER-]Z17.0 Estrogen receptor positive status [ER+]B66.3 FascioliasisE83.111 Hemochromatosis due to repeated red blood cell transfusionsE83.119 Hemochromatosis, unspecified

K74.0 Hepatic fibrosisC22.2 HepatoblastomaK76.81 Hepatopulmonary syndromeE83.110 Hereditary hemochromatosisD64.0 Hereditary sideroblastic anemiaC22.1 Intrahepatic bile duct carcinomaN50.812 Left testicular painC22.0 Liver cell carcinomaC7A.090 Malignant carcinoid tumor of the bronchus and lungC7A.094 Malignant carcinoid tumor of the foregut, unspecifiedC7A.096 Malignant carcinoid tumor of the hindgut, unspecifiedC7A.093 Malignant carcinoid tumor of the kidneyC7A.095 Malignant carcinoid tumor of the midgut, unspecifiedC7A.092 Malignant carcinoid tumor of the stomachC7A.091 Malignant carcinoid tumor of the thymusC7A.00 Malignant carcinoid tumor of unspecified siteC7A.098 Malignant carcinoid tumors of other sitesC38.1 Malignant neoplasm of anterior mediastinumC62.12 Malignant neoplasm of descended left testisC62.11 Malignant neoplasm of descended right testisC56.2 Malignant neoplasm of left ovaryC62.92 Malignant neoplasm of left testis, unspecified whether descended or

undescendedC22.9 Malignant neoplasm of liver, not specified as primary or secondaryC22.8 Malignant neoplasm of liver, primary, unspecified as to typeC38.3 Malignant neoplasm of mediastinum, part unspecifiedC38.8 Malignant neoplasm of overlapping sites of heart, mediastinum and pleuraC38.2 Malignant neoplasm of posterior mediastinumC56.1 Malignant neoplasm of right ovaryC62.91 Malignant neoplasm of right testis, unspecified whether descended or

undescendedC62.02 Malignant neoplasm of undescended left testisC62.01 Malignant neoplasm of undescended right testisC62.10 Malignant neoplasm of unspecified descended testisC56.9 Malignant neoplasm of unspecified ovaryC62.90 Malignant neoplasm of unspecified testis, unspecified whether descended or

undescendedC62.00 Malignant neoplasm of unspecified undescended testisE78.2 Mixed hyperlipidemiaD37.6 Neoplasm of uncertain behavior of liver, gallbladder and bile ductsG89.3 Neoplasm related pain (acute) (chronic)R97.8 Other abnormal tumor markersI74.09 Other arterial embolism and thrombosis of abdominal aortaK73.8 Other chronic hepatitis, not elsewhere classifiedK74.69 Other cirrhosis of liverJ98.59 Other diseases of mediastinum, not elsewhere classifiedE83.09 Other disorders of copper metabolismE83.19 Other disorders of iron metabolismE83.118 Other hemochromatosisN53.8 Other male sexual dysfunctionN44.8 Other noninflammatory disorders of the testisR91.8 Other nonspecific abnormal finding of lung fieldC22.4 Other sarcomas of liverC7B.8 Other secondary neuroendocrine tumorsD64.3 Other sideroblastic anemias

Alpha Sort

Compiled: 12/2019


Alpha-Fetoprotein82105

Alpha Sort—ContinuedC22.7 Other specified carcinomas of liverN50.89 Other specified disorders of the male genital organsN53.12 Painful ejaculationZ86.003 Personal history of in-situ neoplasm of oral cavity, esophagus and stomachZ86.004 Personal history of in-situ neoplasm of other and unspecified digestive organsZ86.002 Personal history of in-situ neoplasm of other and unspecified genital organsZ85.05 Personal history of malignant neoplasm of liverZ85.43 Personal history of malignant neoplasm of ovaryZ85.47 Personal history of malignant neoplasm of testisE88.02 Plasminogen deficiencyN50.811 Right testicular painI74.01 Saddle embolus of abdominal aortaN50.82 Scrotal painC44.1392 Sebaceous cell carcinoma of skin of left lower eyelid, including canthusC44.1391 Sebaceous cell carcinoma of skin of left upper eyelid, including canthusC44.1322 Sebaceous cell carcinoma of skin of right lower eyelid, including canthusC44.1321 Sebaceous cell carcinoma of skin of right upper eyelid, including canthusC7B.03 Secondary carcinoid tumors of boneC7B.01 Secondary carcinoid tumors of distant lymph nodesC7B.02 Secondary carcinoid tumors of liverC7B.09 Secondary carcinoid tumors of other sitesC7B.04 Secondary carcinoid tumors of peritoneumC7B.00 Secondary carcinoid tumors, unspecified siteC79.82 Secondary malignant neoplasm of genital organsC79.62 Secondary malignant neoplasm of left ovaryC78.7 Secondary malignant neoplasm of liver and intrahepatic bile ductC78.1 Secondary malignant neoplasm of mediastinumC79.61 Secondary malignant neoplasm of right ovaryC79.60 Secondary malignant neoplasm of unspecified ovaryC7B.1 Secondary Merkel cell carcinomaD64.1 Secondary sideroblastic anemia due to diseaseD64.2 Secondary sideroblastic anemia due to drugs and toxinsR91.1 Solitary pulmonary noduleA52.74 Syphilis of liver and other visceraN50.819 Testicular pain, unspecifiedQ53.13 Unilateral high scrotal testisQ53.112 Unilateral inguinal testisQ53.111 Unilateral intraabdominal testisR39.83 Unilateral non-palpable testicleK74.60 Unspecified cirrhosis of liverN53.9 Unspecified male sexual dysfunctionE83.01 Wilson’s disease

Numeric SortA52.74B18.0B18.1B18.2B66.1B66.3C22.0C22.1C22.2C22.3C22.4C22.7C22.8C22.9C38.1C38.2C38.3C38.8C44.1321C44.1322C44.1391C44.1392C56.1C56.2C56.9C62.00C62.01C62.02C62.10C62.11C62.12C62.90C62.91C62.92C78.1C78.7C79.60C79.61C79.62C79.82C7A.00C7A.090C7A.091C7A.092C7A.093C7A.094C7A.095C7A.096C7A.098C7B.00C7B.01C7B.02C7B.03C7B.04C7B.09

C7B.1C7B.8D13.4D13.5D37.6D64.0D64.1D64.2D64.3D81.810D84.1E78.2E83.00E83.01E83.09E83.10E83.110E83.111E83.118E83.119E83.19E84.19E84.9E88.01E88.02G89.3I25.84I74.01I74.09I74.10I74.19J98.59K70.2K70.30K70.31K73.0K73.1K73.2K73.8K73.9K74.0K74.60K74.69K75.4K76.81N44.1N44.2N44.8N50.3N50.811N50.812N50.819N50.82N50.89N53.12

N53.8N53.9Q53.111Q53.112Q53.13Q53.211Q53.212Q53.23R39.83R39.84R91.1R91.8R93.1R93.2R93.5R93.811R93.812R93.813R93.819R93.89R97.8Z04.81Z04.82Z04.89Z13.40Z13.41Z13.42Z13.49Z17.0Z17.1Z85.05Z85.43Z85.47Z86.002Z86.003Z86.004

Compiled: 12/2019

Assays for Vitamins and Metabolic Function82180, 82306, 82379, 82607, 82652, 82746, 83090, 83698, 84207, 84252, 84255, 84425, 84446, 84590, 84591, 84597, 84999, 85385, 86352

For Medicare beneficiaries, screening tests are governed by statute. Vitamin or micronutrient testing may not be used for routine screening.

Once a beneficiary has been shown to be vitamin deficient, further testing is medically necessary only to ensure adequate replacement has been accomplished. Thereafter, annual testing may be appropriate depending upon the indication and other mitigating factors.

The following tests are considered non-covered services:

• Assays of selenium (84255)• Functional intracellular analysis (84999)• Total antioxidant function (84999)• Assays of vitamin testing, not otherwise classified* (84591)

*Note: Assays of vitamin testing, not otherwise classified (84591) is not covered since all clinically relevant vitamins have specific assays.

Notice: This LCD imposes the following limitations to the tests addressed in this LCD. These limitations will support automated denials as follows:

• Noncovered as described above (84255, 84999, 84591)• Diagnosis to procedure limitations only (86352)• Frequency limitations* only (82180, 84252, 84425, 84446, 84590, 84597)• Diagnosis to procedure and frequency limitations* (82306, 82652, 82379, 82607,

82746, 83090, 84207, 85385, 83698)

Utilization Guidelines

Medicare recognizes certain tests may exceed the stated frequencies. Should a denial occur, additional documentation can be submitted to support medical necessity. Payment for additional tests may be allowed in selected circumstances when, upon medical review, the medical necessity of additional services is demonstrated.

Following a review of utilization data at various percentiles of units billed per year, the following frequency limitations are established and are as follows:

82180 (Assay of ascorbic acid) 1 time per year82306 (Vitamin d 25 hydroxy) up to 3 times per year82379 (Assay of carnitine) up to 3 times per year82607 (Vitamin b-12) up to 3 times per year82652 (Vit d 1 25-dihydroxy) up to 2 times per year82746 (Assay of folic acid serum) up to 3 times per year83090 (Assay of homocysteine) 1 time per year83698 (Assay lipoprotein pla2) 1 time per year84207 (Assay of vitamin b-6) 1 time per year84252 (Assay of vitamin b-2) 1 time per year84425 (Assay of vitamin b-1) 1 time per year 84446 (Assay of vitamin e) 1 time per year84590 (Assay of vitamin a) 1 time per year84597 (Assay of vitamin k) 1 time per year85385 (Fibrinogen antigen) up to 3 times per year86352 (Cell function assay w/stim) frequencies not determined

Medicare is establishing the following limited coverage for CPT/HCPCS codes 82306 and 82652:

L40.2 Acrodermatitis continuaA19.0 Acute miliary tuberculosis of a single specified siteA19.1 Acute miliary tuberculosis of multiple sites

A19.2 Acute miliary tuberculosis, unspecifiedM83.2 Adult osteomalacia due to malabsorptionM83.3 Adult osteomalacia due to malnutritionM83.9 Adult osteomalacia, unspecifiedM80.072A Age-related osteoporosis with current pathological fracture, left ankle and foot,

initial encounter for fractureM80.072S Age-related osteoporosis with current pathological fracture, left ankle and foot,

sequelaM80.072G Age-related osteoporosis with current pathological fracture, left ankle and foot,

subsequent encounter for fracture with delayed healingM80.072P Age-related osteoporosis with current pathological fracture, left ankle and foot,

subsequent encounter for fracture with malunionM80.072K Age-related osteoporosis with current pathological fracture, left ankle and foot,

subsequent encounter for fracture with nonunionM80.072D Age-related osteoporosis with current pathological fracture, left ankle and foot,

subsequent encounter for fracture with routine healingM80.052A Age-related osteoporosis with current pathological fracture, left femur, initial

encounter for fractureM80.052S Age-related osteoporosis with current pathological fracture, left femur, sequelaM80.052G Age-related osteoporosis with current pathological fracture, left femur,

subsequent encounter for fracture with delayed healingM80.052P Age-related osteoporosis with current pathological fracture, left femur,

subsequent encounter for fracture with malunionM80.052K Age-related osteoporosis with current pathological fracture, left femur,

subsequent encounter for fracture with nonunionM80.052D Age-related osteoporosis with current pathological fracture, left femur,

subsequent encounter for fracture with routine healingM80.032A Age-related osteoporosis with current pathological fracture, left forearm, initial

encounter for fractureM80.032S Age-related osteoporosis with current pathological fracture, left forearm, sequelaM80.032G Age-related osteoporosis with current pathological fracture, left forearm,

subsequent encounter for fracture with delayed healingM80.032P Age-related osteoporosis with current pathological fracture, left forearm,

subsequent encounter for fracture with malunionM80.032K Age-related osteoporosis with current pathological fracture, left forearm,

subsequent encounter for fracture with nonunionM80.032D Age-related osteoporosis with current pathological fracture, left forearm,

subsequent encounter for fracture with routine healingM80.042A Age-related osteoporosis with current pathological fracture, left hand, initial

encounter for fractureM80.042S Age-related osteoporosis with current pathological fracture, left hand, sequelaM80.042G Age-related osteoporosis with current pathological fracture, left hand, subsequent

encounter for fracture with delayed healingM80.042P Age-related osteoporosis with current pathological fracture, left hand, subsequent

encounter for fracture with malunionM80.042K Age-related osteoporosis with current pathological fracture, left hand, subsequent

encounter for fracture with nonunionM80.042D Age-related osteoporosis with current pathological fracture, left hand, subsequent

encounter for fracture with routine healingM80.022A Age-related osteoporosis with current pathological fracture, left humerus, initial

encounter for fractureM80.022S Age-related osteoporosis with current pathological fracture, left humerus, sequelaM80.022G Age-related osteoporosis with current pathological fracture, left humerus,

subsequent encounter for fracture with delayed healingM80.022P Age-related osteoporosis with current pathological fracture, left humerus,

subsequent encounter for fracture with malunionM80.022K Age-related osteoporosis with current pathological fracture, left humerus,

subsequent encounter for fracture with nonunion

Alpha Sort

Novitas Solutions, Inc — Delaware, District of Columbia, Maryland, New Jersey, Pennsylvania

Limitations:

Compiled: 12/2019



Alpha Sort—ContinuedM80.031K Age-related osteoporosis with current pathological fracture, right forearm,

subsequent encounter for fracture with nonunionM80.031D Age-related osteoporosis with current pathological fracture, right forearm,

subsequent encounter for fracture with routine healingM80.041A Age-related osteoporosis with current pathological fracture, right hand, initial

encounter for fractureM80.041S Age-related osteoporosis with current pathological fracture, right hand, sequelaM80.041G Age-related osteoporosis with current pathological fracture, right hand,

subsequent encounter for fracture with delayed healingM80.041P Age-related osteoporosis with current pathological fracture, right hand,

subsequent encounter for fracture with malunionM80.041K Age-related osteoporosis with current pathological fracture, right hand,

subsequent encounter for fracture with nonunionM80.041D Age-related osteoporosis with current pathological fracture, right hand,

subsequent encounter for fracture with routine healingM80.021A Age-related osteoporosis with current pathological fracture, right humerus, initial

encounter for fractureM80.021S Age-related osteoporosis with current pathological fracture, right humerus,

sequelaM80.021G Age-related osteoporosis with current pathological fracture, right humerus,

subsequent encounter for fracture with delayed healingM80.021P Age-related osteoporosis with current pathological fracture, right humerus,

subsequent encounter for fracture with malunionM80.021K Age-related osteoporosis with current pathological fracture, right humerus,

subsequent encounter for fracture with nonunionM80.021D Age-related osteoporosis with current pathological fracture, right humerus,

subsequent encounter for fracture with routine healingM80.061A Age-related osteoporosis with current pathological fracture, right lower leg, initial

encounter for fractureM80.061S Age-related osteoporosis with current pathological fracture, right lower leg,

sequelaM80.061G Age-related osteoporosis with current pathological fracture, right lower leg,

subsequent encounter for fracture with delayed healingM80.061P Age-related osteoporosis with current pathological fracture, right lower leg,

subsequent encounter for fracture with malunionM80.061K Age-related osteoporosis with current pathological fracture, right lower leg,

subsequent encounter for fracture with nonunionM80.061D Age-related osteoporosis with current pathological fracture, right lower leg,

subsequent encounter for fracture with routine healingM80.011A Age-related osteoporosis with current pathological fracture, right shoulder, initial

encounter for fractureM80.011S Age-related osteoporosis with current pathological fracture, right shoulder,

sequelaM80.011G Age-related osteoporosis with current pathological fracture, right shoulder,

subsequent encounter for fracture with delayed healingM80.011P Age-related osteoporosis with current pathological fracture, right shoulder,

subsequent encounter for fracture with malunionM80.011K Age-related osteoporosis with current pathological fracture, right shoulder,

subsequent encounter for fracture with nonunionM80.011D Age-related osteoporosis with current pathological fracture, right shoulder,

subsequent encounter for fracture with routine healingM80.079A Age-related osteoporosis with current pathological fracture, unspecified ankle and

foot, initial encounter for fractureM80.079S Age-related osteoporosis with current pathological fracture, unspecified ankle and

foot, sequelaM80.079G Age-related osteoporosis with current pathological fracture, unspecified ankle and

foot, subsequent encounter for fracture with delayed healingM80.079P Age-related osteoporosis with current pathological fracture, unspecified ankle and

foot, subsequent encounter for fracture with malunion

M80.022D Age-related osteoporosis with current pathological fracture, left humerus, subsequent encounter for fracture with routine healing

M80.062A Age-related osteoporosis with current pathological fracture, left lower leg, initial encounter for fracture

M80.062S Age-related osteoporosis with current pathological fracture, left lower leg, sequela

M80.062G Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with delayed healing

M80.062P Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with malunion

M80.062K Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with nonunion

M80.062D Age-related osteoporosis with current pathological fracture, left lower leg, subsequent encounter for fracture with routine healing

M80.012A Age-related osteoporosis with current pathological fracture, left shoulder, initial encounter for fracture

M80.012S Age-related osteoporosis with current pathological fracture, left shoulder, sequelaM80.012G Age-related osteoporosis with current pathological fracture, left shoulder,

subsequent encounter for fracture with delayed healingM80.012P Age-related osteoporosis with current pathological fracture, left shoulder,

subsequent encounter for fracture with malunionM80.012K Age-related osteoporosis with current pathological fracture, left shoulder,

subsequent encounter for fracture with nonunionM80.012D Age-related osteoporosis with current pathological fracture, left shoulder,

subsequent encounter for fracture with routine healingM80.071A Age-related osteoporosis with current pathological fracture, right ankle and foot,

initial encounter for fractureM80.071S Age-related osteoporosis with current pathological fracture, right ankle and foot,

sequelaM80.071G Age-related osteoporosis with current pathological fracture, right ankle and foot,

subsequent encounter for fracture with delayed healingM80.071P Age-related osteoporosis with current pathological fracture, right ankle and foot,

subsequent encounter for fracture with malunionM80.071K Age-related osteoporosis with current pathological fracture, right ankle and foot,

subsequent encounter for fracture with nonunionM80.071D Age-related osteoporosis with current pathological fracture, right ankle and foot,

subsequent encounter for fracture with routine healingM80.051A Age-related osteoporosis with current pathological fracture, right femur, initial

encounter for fractureM80.051S Age-related osteoporosis with current pathological fracture, right femur, sequelaM80.051G Age-related osteoporosis with current pathological fracture, right femur,

subsequent encounter for fracture with delayed healingM80.051P Age-related osteoporosis with current pathological fracture, right femur,

subsequent encounter for fracture with malunionM80.051K Age-related osteoporosis with current pathological fracture, right femur,

subsequent encounter for fracture with nonunionM80.051D Age-related osteoporosis with current pathological fracture, right femur,

subsequent encounter for fracture with routine healingM80.031A Age-related osteoporosis with current pathological fracture, right forearm, initial

encounter for fractureM80.031S Age-related osteoporosis with current pathological fracture, right forearm,

sequelaM80.031G Age-related osteoporosis with current pathological fracture, right forearm,

subsequent encounter for fracture with delayed healingM80.031P Age-related osteoporosis with current pathological fracture, right forearm,

subsequent encounter for fracture with malunion

Medicare is establishing the following limited coverage for CPT/HCPCS codes 82306 and 82652 —Continued:

Compiled: 12/2019



Alpha Sort—ContinuedM80.069G Age-related osteoporosis with current pathological fracture, unspecified lower

leg, subsequent encounter for fracture with delayed healingM80.069P Age-related osteoporosis with current pathological fracture, unspecified lower

leg, subsequent encounter for fracture with malunionM80.069K Age-related osteoporosis with current pathological fracture, unspecified lower

leg, subsequent encounter for fracture with nonunionM80.069D Age-related osteoporosis with current pathological fracture, unspecified lower

leg, subsequent encounter for fracture with routine healingM80.019A Age-related osteoporosis with current pathological fracture, unspecified shoulder,

initial encounter for fractureM80.019S Age-related osteoporosis with current pathological fracture, unspecified shoulder,

sequelaM80.019G Age-related osteoporosis with current pathological fracture, unspecified shoulder,

subsequent encounter for fracture with delayed healingM80.019P Age-related osteoporosis with current pathological fracture, unspecified shoulder,

subsequent encounter for fracture with malunionM80.019K Age-related osteoporosis with current pathological fracture, unspecified shoulder,

subsequent encounter for fracture with nonunionM80.019D Age-related osteoporosis with current pathological fracture, unspecified shoulder,

subsequent encounter for fracture with routine healingM80.00XA Age-related osteoporosis with current pathological fracture, unspecified site,

initial encounter for fractureM80.00XS Age-related osteoporosis with current pathological fracture, unspecified site,

sequelaM80.00XG Age-related osteoporosis with current pathological fracture, unspecified site,

subsequent encounter for fracture with delayed healingM80.00XP Age-related osteoporosis with current pathological fracture, unspecified site,

subsequent encounter for fracture with malunionM80.00XK Age-related osteoporosis with current pathological fracture, unspecified site,

subsequent encounter for fracture with nonunionM80.00XD Age-related osteoporosis with current pathological fracture, unspecified site,

subsequent encounter for fracture with routine healingM80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial

encounter for fractureM80.08XS Age-related osteoporosis with current pathological fracture, vertebra(e), sequelaM80.08XG Age-related osteoporosis with current pathological fracture, vertebra(e),

subsequent encounter for fracture with delayed healingM80.08XP Age-related osteoporosis with current pathological fracture, vertebra(e),

subsequent encounter for fracture with malunionM80.08XK Age-related osteoporosis with current pathological fracture, vertebra(e),

subsequent encounter for fracture with nonunionM80.08XD Age-related osteoporosis with current pathological fracture, vertebra(e),

subsequent encounter for fracture with routine healingM81.0 Age-related osteoporosis without current pathological fractureK70.31 Alcoholic cirrhosis of liver with ascitesK70.30 Alcoholic cirrhosis of liver without ascitesK70.2 Alcoholic fibrosis and sclerosis of liverM83.4 Aluminum bone diseaseL40.50 Arthropathic psoriasis, unspecifiedZ98.84 Bariatric surgery statusJ63.2 BerylliosisK74.5 Biliary cirrhosis, unspecifiedK83.5 Biliary cystK90.2 Blind loop syndrome, not elsewhere classifiedZ68.30 Body mass index (BMI) 30.0-30.9, adultZ68.31 Body mass index (BMI) 31.0-31.9, adultZ68.32 Body mass index (BMI) 32.0-32.9, adultZ68.33 Body mass index (BMI) 33.0-33.9, adult

M80.079K Age-related osteoporosis with current pathological fracture, unspecified ankle and foot, subsequent encounter for fracture with nonunion

M80.079D Age-related osteoporosis with current pathological fracture, unspecified ankle and foot, subsequent encounter for fracture with routine healing

M80.059A Age-related osteoporosis with current pathological fracture, unspecified femur, initial encounter for fracture

M80.059S Age-related osteoporosis with current pathological fracture, unspecified femur, sequela

M80.059G Age-related osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with delayed healing

M80.059P Age-related osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with malunion

M80.059K Age-related osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with nonunion

M80.059D Age-related osteoporosis with current pathological fracture, unspecified femur, subsequent encounter for fracture with routine healing

M80.039A Age-related osteoporosis with current pathological fracture, unspecified forearm, initial encounter for fracture

M80.039S Age-related osteoporosis with current pathological fracture, unspecified forearm, sequela

M80.039G Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with delayed healing

M80.039P Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with malunion

M80.039K Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with nonunion

M80.039D Age-related osteoporosis with current pathological fracture, unspecified forearm, subsequent encounter for fracture with routine healing

M80.049A Age-related osteoporosis with current pathological fracture, unspecified hand, initial encounter for fracture

M80.049S Age-related osteoporosis with current pathological fracture, unspecified hand, sequela

M80.049G Age-related osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with delayed healing

M80.049P Age-related osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with malunion

M80.049K Age-related osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with nonunion

M80.049D Age-related osteoporosis with current pathological fracture, unspecified hand, subsequent encounter for fracture with routine healing

M80.029A Age-related osteoporosis with current pathological fracture, unspecified humerus, initial encounter for fracture

M80.029S Age-related osteoporosis with current pathological fracture, unspecified humerus, sequela

M80.029G Age-related osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with delayed healing

M80.029P Age-related osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with malunion

M80.029K Age-related osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with nonunion

M80.029D Age-related osteoporosis with current pathological fracture, unspecified humerus, subsequent encounter for fracture with routine healing

M80.069A Age-related osteoporosis with current pathological fracture, unspecified lower leg, initial encounter for fracture

M80.069S Age-related osteoporosis with current pathological fracture, unspecified lower leg, sequela

Medicare is establishing the following limited coverage for CPT/HCPCS codes 82306 and 82652—Continued:

Compiled: 12/2019

Novitas Solutions, Inc — Delaware, District of Columbia,

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